Case presentationA 73-year-old man presented with a 4-week history of diarrhoea and 2-week history of confusion. He was a retired nuclear scientist who was previously fully independent with no history of cognitive impairment. There was no history of smoking, alcohol or substance abuse.His wife reported cognitive disturbances including being unable to use a cassette player or turn on his electric razor and he had started urinating in the sink. He was visited by his GP who found him confused, drowsy and dehydrated. Observations were unremarkable but a rectal examination showed hard stool in the rectum. Presuming a urinary tract infection, laxatives and trimethoprim were prescribed and he was transferred to hospital for further investigations.On admission there were no infective signs or symptoms. His cardiovascular, respiratory and abdominal examinations were unremarkable. He was extremely delirious requiring sedation and occasional reasonable physical restraint. He scored 3/10 on the Abbreviated Mental Test Score (AMTS) but had no other neurological signs. His electrocardiogram (ECG), chest X-ray (CXR) and computed tomography (CT) brain were all normal. Admission blood test results are shown in Table 1 .
DiagnosisInvestigations for his hypercalcaemia revealed low parathyroid hormone 0.6 pmol/L and a toxic 25-hydroxyvitamin D (25[OH]D) ABSTRACT concentration 881 nmol/L (normal range 25-100 nmol/L), suggesting a diagnosis of hypervitaminosis D. Other causes of hypercalcaemia such as malignancy, thyroid disease and sarcoidosis were excluded. On further questioning his daughter reported he had been taking 60,000 IU vitamin D capsules per day for the last 2 years having read a book advocating its health benefits.
The Ambulatory Care Unit (ACU) is a recent addition to Basingstoke and North Hampshire Hospital. In January 2017, additional acute medical consultants were appointed to help develop the service. The clinic is consultant led and operates Monday-Friday from 09.00-18.00. ACU accepts referrals directly from GPs and operates a push/pull system for the Emergency Department (ED). Out-of-hours referrals can be made via the medical registrar on call. Before expanding the service further, we studied the true impact of ACU by looking not only at patients diverted from the medical take, but also at 30-day readmission rates and mortality, thereby reflecting 'true' admission avoidance (TAA).
Cardiac troponin I and T are particularly sensitive and specific markers for cardiomyocyte damage. Myocardial injury can occur due to a discrepancy between oxygen supply and demand (eg coronary artery occlusion and arrhythmias), other cardiac causes (eg pericarditis, myocarditis, cardiac surgery, cardioversion etc) or systemic conditions (eg sepsis, stroke and chronic renal disease). The latest European Society of Cardiology guidelines help to guide clinicians through these different causes. Occasionally troponin concentrations may not fit the clinical presentation and, therefore, other aetiologies should be considered. An under-appreciated basis of a high troponin concentration is a false positive result, which can be attributable to analytical interference from components in the patient's blood. Uncovering this interference can be pivotal to avoid unnecessary and potentially harmful investigations or treatment for patients. We present two cases of false positive troponin results caused by analytical interference. The normal reference range for the assay (Access; Beckman Coulter, High Wycombe, UK) used at our organisation is 0-18 ng/L.
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