Simultaneous multifocal intracranial haemorrhage (ICH) and subarachnoid haemorrhage (SAH) in the setting of long-term cocaine usage.

A 45-year-old Caucasian man was admitted to hospital following a collapse at home. On admission, this patient was noted to have a Glasgow Coma Scale (GCS) Score of 9 out of 15, fever and tachypnoea. The patient was identified to have bilateral limb weakness, predominately on the left side, with associated dysphagia. Radiological imaging demonstrated bilateral multifocal intracranial haemorrhage and subarachnoid haemorrhage. Neurosurgical input was sought; the outcome of this was a decision to manage the patient conservatively, without surgical intervention. Of note, his urine drug testing revealed a positive result for a cocktail of drugs including cocaine, benzoylecgonine (cocaine metabolite), methadone, heroin, norbuprenorphine and benzodiazepine. Throughout the admission, the patient was monitored in an intensive care setting. The patient received support with feeding, speech and mobilisation. The patients' GCS improved throughout the admission. Following a 30-day admission, the patient walked home.

Clinical course of a 66-year-old man with an acute ischaemic stroke in the setting of a COVID-19 infection.

A 66-year-old man was admitted to hospital with a right frontal cerebral infarct producing left-sided weakness and a deterioration in his speech pattern. The cerebral infarct was confirmed with CT imaging. The only evidence of respiratory symptoms on admission was a 2 L oxygen requirement, maintaining oxygen saturations between 88% and 92%. In a matter of hours this patient developed a greater oxygen requirement, alongside reduced levels of consciousness. A positive COVID-19 throat swab, in addition to bilateral pneumonia on chest X-ray and lymphopaenia in his blood tests, confirmed a diagnosis of COVID-19 pneumonia. A proactive decision was made involving the patients' family, ward and intensive care healthcare staff, to not escalate care above a ward-based ceiling of care. The patient died 5 days following admission under the palliative care provided by the medical team.

The identification of acute stroke: an analysis of emergency calls.

BACKGROUND: Accurate dispatch of emergency medical services at the onset of acute stroke is vital in expediting assessment and treatment. We examined the relationship between callers' description of potential stroke symptoms to the emergency medical dispatcher and the subsequent classification and prioritisation of emergency medical services response. AIM: To identify key 'indicator' words used by people making emergency calls for suspected stroke, comparing these with the subsequent category of response given by the emergency medical dispatcher. METHOD: A retrospective chart review (hospital and emergency medical services) in North West England (October 1, 2006 to September 30, 2007) identified digitally recorded emergency medical services calls, which related to patients who had a diagnosis of suspected stroke at some point on the stroke pathway (from the emergency medical services call taker through to final medical diagnosis). Using content analysis, words used to describe stroke by the caller were recorded. A second researcher independently followed the same procedure in order to produce a list of 'indicator' words. Description of stroke-specific and nonstroke-specific problems reported by the caller was compared with subsequent emergency medical services dispatch coding and demographic features. RESULTS: Six hundred forty-three calls were made to emergency medical services of which 592 (92%) had complete emergency medical services and hospital data. The majority of callers were female (67%) and family members (55%). The most frequently reported problems first said by callers to the emergency medical dispatcher were collapse or fall (26%) and stroke (25%). Callers who identified that the patient was having a stroke were correct in 89% of cases. Calls were dispatched as stroke in 45% of cases, of which 83% had confirmed stroke. Of the first reported problems, Face Arm Speech Test stroke symptoms were mentioned in less than 5% of calls, with speech problems being the most common symptom. No callers mentioned all three Face Arm Speech Test symptoms. CONCLUSION: Callers who contacted emergency medical services for suspected stroke and said stroke as the first reported problem were often correct. Calls categorised as stroke by the emergency medical dispatcher were commonly confirmed as stroke in the hospital. Speech problems were the most commonly reported element of the Face Arm Speech Test test to be reported by callers. Recognition of possible stroke diagnosis in fall and other presentations should be considered by emergency medical dispatchers. Further development and training are needed in the community to improve prehospital stroke recognition in order to expedite hyperacute stroke care.

The incidence of oral Gram-negative bacteria in patients with Parkinson's disease.

Background: Parkinson's disease is a common neurodegenerative disorder that affects an increasing number of older people every year. Dysphagia is not only a common feature, but one that results in poor nutrition and an increased risk of bronchopneumonia. Previous work has suggested that the oral flora is altered in patients with oral pathology. Methods: Fifty patients were assessed to quantify the incidence of oral Gram-negative bacteria. Results: Sixteen of the patients with Parkinson's disease were found to have six different Gram-negative bacilli in their oral cavities. The 20 different Gram-negative bacteria present were Escherichia coli (n=7), Klebsiella spp. (n=3), Kluyvera spp. (n=3), Serratia spp. (n=3), Proteus spp. (n=2) and Enterobacter spp. (n=2). We found that the oral cavity of 16 (32%) of the patients with Parkinson's disease was abnormally colonised with Gram-negative bacteria and that Gram-negative bacteria were more likely to occur in those patients in whom oromuscular dysfunction was present (88% vs. 21%; p<0.05). Conclusion: Further work is required to determine the association between oral flora and the pathogenic organisms found in aspiration pneumonia as well as work on innovative treatments to reduce oral Gram-negative bacteria in those patients at particular risk of aspiration pneumonia.