A 40-year-old man developed acute brainstem dysfunction 3 days after hospital admission with symptoms of the novel SARS-CoV-2 infection (COVID-19). Magnetic resonance imaging showed changes in keeping with inflammation of the brainstem and the upper cervical cord, leading to a diagnosis of rhombencephalitis. No other cause explained the patient's abnormal neurological findings. He was managed conservatively with rapid spontaneous improvement in some of his neurological signs and was discharged home with continued neurology follow up.A 40-year-old never-smoker with minimum alcohol intake, originally from Nigeria and now settled in the UK with his family after moving here 7 years ago, attended the emergency department reporting a 10-day history of persistent fever and progressive dyspnoea on exertion while self-isolating at home during the COVID-19 crisis. He was on long-term treatment with ramipril and amlodipine for hypertension and on dorzolamide (a carbonic anhydrase inhibitor) with timolol maleate eye drops for closed angle glaucoma. He reported malaise, a new cough with yellow sputum and diarrhoea (non-bloody) over 3 days. There was no recent foreign travel or family history of medical conditions but he shared the concern that his wife was currently pregnant.On presentation, temperature was 38.4°C, heart rate regular at 86 beats/minute, blood pressure 129/83 mmHg; oxygen saturation 93% on room air as he was tachypnoeic at 32 breaths/minute. On auscultation, heart sounds were normal but there were bi-basal ABSTRACT Authors: A ST4 Respiratory Medicine, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; B clinical fellow, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; C consultant neurologist, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; D consultant respiratory physician, The Shrewsbury and Telford Hospital NHS Trust, Telford, UKcrackles. There was no gross focal neurological deficit. Initial 12-lead electrocardiography showed sinus tachycardia and chest X-ray showed a right lower zone consolidation. Arterial blood gas on room air revealed hypoxia (PaO 2 8.77 kPa) with pH 7.432, PaCO 2 4.21 kPa, HCO 3-20.6 mmol/L, base excess 2.6 mmol/L, lactate 0.98 mmol/L. Haemoglobin was 139 g/L, white cell count 7.0 × 10 9 /L (lymphocytes 1.2 × 10 9 /L) and C-reactive protein (CRP) marginally raised at 50 mg/L, and similar slight increases were seen in serum gamma glutamyl transferase (GGT) 107 U/L (range 0-75) and alanine aminotransferase (ALT) 88 U/L (range 0-45), with other liver tests and urinary electrolytes within the normal ranges.
Sleep disturbances are common in pregnancy and affect sleep quality. The maternal body is going through constant physical and physiological changes to adapt to the growing fetus. Sleep disorders may manifest at any point during pregnancy; some may result in adverse maternal or fetal outcomes. A strong clinical suspicion is crucial to identify sleep disorders in pregnancy and their management should be evaluated with a multidisciplinary team approach. In this review, we provide an overview of changes in sleep during pregnancy and summarise the key features of common sleep disorders in pregnancy, including practical tips on their management.Educational aimsTo provide an overview of common sleep disorders in pregnancy and their management options.To highlight the impact of the physiological changes in pregnancy on sleep.To outline the type of sleep studies available to investigate sleep disorders in pregnancy.
Thrombocytosis has a positive predictive value for detecting malignancy and in patients with lung cancer independently also predicts prognosis. Investigating patients predominantly with non-small cell lung cancer (NSCLC), objectives were to (1) establish how platelet counts correlate with SUV/FDG uptake on PET (Positron Emission Tomography), and (2) determine whether thrombocytosis (normal range 150 to 400 x 10 9 /L) is more prevalent in patients with positive molecular markers for lung cancer.METHODS: Retrospective analysis of 114 patients (50% male), mean age 71.9 (SD 8.7, range 29-87) years, undergoing PET scanning prior to intended thoracic surgery. Comparative analysis was with standard statistical methods using SPSS investigating absolute platelet counts or adopting an upper threshold at 400 x 10 9 /L separating patients with normal from those with high platelet counts. Molecular markers (EGFR, ALK, ROS-1, PDL-1) were reported positive detected alone or in combination and were negative where absent or where PDL-1 was <1%. Bias arose from only surgical candidates being considered; potential errors arose from inclusion of any non-lung malignancy.RESULTS: Two patients had low (<2.5) SUV on PET scans; overall distribution was within a range 0.8 to 75.4. At the primary lung site, SUV uptake correlated positively but weakly with the absolute platelet count, r s (Spearman rho) =0.26, p¼0.007. In patients with thrombocytosis there was no statistical difference comparing where PET scans identified involved nodes 17/53(32%) versus not 13/55(24%), (x 2 0.9582, p=.3277), and similarly where distal metastatic disease was present 9/24 (38%) versus absent 21/85 (25%), (x 2 1.5358, p=.2152). 96/114 (84%) patients had histologically proven NSCLC; 3 others were pleomorphic, 5 carcinoid, 1 colo-rectal, 5 null and 4 small cell lung cancer. Where molecular test results were available (n¼89), comparing those with positive (n¼41) versus negative tests (n¼48), mean platelet counts (x10 9 ) were respectively 344 and 330, t¼0.547, p¼0.293, not significant; platelet counts were raised in 13/41(32%) of patients with detected molecular markers versus 12/48 (25%) in those without (negative) but this was not statistically different (x 2 0.4925, p=.4828). PDL-1 had dominated (n¼39) but analysed separately showed no statistical significance. CONCLUSIONS: Absolute platelet counts correlated positively with PET scan uptake for malignancy in the lung but thrombocytosis at the adopted threshold (> 400 x 10 9 /L) did not predict staging at nodal or distal metastatic sites or when testing for NSCLC associated molecular markers. As with continued work elsewhere screening for malignancy, research is required to establish gender differences and different threshold cut offs potentially within the normal range for platelet counts.CLINICAL IMPLICATIONS: If raised platelet counts are shown to correlate with uptake on PET scan and/or molecular markers associated with non small cell lung cancer, this may then improve referrals for these tests and help ea...
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