Vestibular neuronitis after COVID-19 vaccination.

A woman in her 50s presented with acute vertigo and vomiting within 72 hours of receiving the Pfizer-BioNTech COVID-19 vaccine. The only neurological deficit was an impaired vestibulo-ocular reflex with horizontal nystagmus. The patient was subsequently diagnosed with vestibular neuronitis. She was managed symptomatically with prochlorperazine and betahistine, and underwent vestibular rehabilitation for 6 weeks. She made a full recovery and experienced no further symptoms. She received the second dose of the vaccine without complications.This case demonstrates a temporal association between COVID-19 vaccination and vestibular neuronitis. Neurological adverse events are rare but recognised side effects of COVID-19 vaccines and healthcare professionals should be aware of them. This ensures timely management of patients with such presentations. Treatment should be the same as for non-vaccine-associated vestibular neuronitis. The nature of the relationship between COVID-19 vaccination and vestibular neuronitis remains unclear and patients therefore require investigations to exclude other recognised causes of vestibular neuronitis.

Bilateral loss of taste from a unilateral thalamic infarct.

Loss of sense of taste (hypogeusia) involving a part of the tongue can follow acute stroke. We describe a woman with a small right thalamic acute infarct causing bilateral (mainly left-sided) hypogeusia. Her problem remains sufficiently severe to cause distress and nutritional deficit. The anatomical distribution of her problem-cheiro-oral syndrome with concurrent hypogeusia-suggested involvement of adjacent relevant thalamic fibres. We address key considerations in examining taste in research and in practice and discuss issues to address in people with hypogeusia, including swallow deficits, psychological elements of the poststroke condition and nutrition. Dietetic management should include optimising taste stimuli and nutritional support. Introducing more detailed taste assessments into standard practice would likely improve stroke unit care.

Multiorgan thromboembolic shower and its ethical implications.

A 54 year-old man was admitted after being found on the floor of his home, thought to have been there for approximately 5 days. He was diagnosed with a non-ST elevation myocardial infarction and bilateral cerebral ischaemic infarcts, as well as an acute kidney injury driven by rhabdomyolysis. The following day, bilateral lower limb ischaemia was observed. A full body CT angiogram revealed a complete thromboembolic shower with bilateral arterial occlusion in the lower limbs, bilateral pulmonary emboli, a splenic infarct and mesenteric ischaemia. An echocardiogram revealed a large thrombus in the left ventricle as the likely thromboembolic source. Bilateral lower limb amputations were recommended, commencing a complex discussion regarding the best course of management for this patient. The discussion was multifaceted, owing to the patient's lack of capacity, and input from multiple teams and the patient's relatives was required. Both ethical and clinical challenges arise from this case of a thromboembolic shower.

Reflecting on the importance of work experience for the next generation of doctors.

A stroke consultant and pre-medical student discuss the benefits of work experience and their respective engagement in placement programmes.

Impact of COVID-19 on Stroke Caseload in a Major Hyperacute Stroke Unit.

Northwick Park Hospital in London, United Kingdom (UK) is one of the busiest stroke units in the country and is located in one of the areas most heavily affected by the COVID-19 pandemic in the first half of 2020. Admissions to the stroke unit and changes during the peak of COVID-19 were reviewed. Compared with the previous year, mean 96 patients were admitted with suspected stroke during April and May 2020 compared with mean 116 per month in non-COVID periods, ratio 0.82, P = 0.01. This reduction involved both strokes and mimics and was unlikely to have occurred by chance. Numbers of patients thrombolysed and of patients referred for thrombectomy decreased dramatically during this time. Mechanisms by which the COVID-19 pandemic and the March lockdown may have affected admissions to the unit are discussed. Reduced admissions to the stroke unit allowed it to contribute its resources to the care of patients with COVID-19 during the peak of admissions.

Nutritional assessment in elderly care: a MUST!

Malnutrition affects over three million people in the UK with associated health costs exceeding £13 billion annually.[1] In hospital, malnutrition has been shown to increase complication rates, morbidity, mortality, hospital readmissions, and length of hospital stay.[2] To screen for malnutrition, a reliable and validated screening tool such as the malnutrition universal screening tool (MUST) should be used.[3] We believe that improved patient outcomes and significant savings to the trust can be achieved, not only by ensuring that every patient has a MUST score documented, but that it is calculated correctly and the appropriate interventions are implemented. We have carried out the audit three times (May, July, and November 2013). The study included the patients on the elderly care ward of Watford General Hospital (n=64, 62, and 63 respectively). MUST scores documented in nursing notes for each patient were noted. We re-calculated each MUST score ourselves for comparison. We went through patient notes and nursing information and noted which recommended nutritional interventions were being implemented. Our results highlighted several issues: 1) Patients did not consistently have a MUST score documented 2) MUST scores were calculated incorrectly. This was generally due to BMIs calculated incorrectly, and patients' weights from six months ago not being known 3) High MUST scores not being acted on appropriately. Our interventions have involved liaising with various teams within the hospital to maximise the efficacy of the MUST score. This has included encouraging the trust to provide regular training to nurses because of high nursing staff turnover. Following our audit, the dietitian department agreed to undertake weekly ward rounds to screen for patients at risk of malnutrition. Our interventions so far have resulted in increased proportion of MUST scores being calculated (73 to 97%), and increased rates of patients being referred to dietitians (62 to 86% in the second audit cycle).