A 76-year-old man was admitted to hospital with a right-sided fractured neck of femur requiring repair via a cemented hemiarthroplasty. Intraoperatively he received 10 mg of intravenous morphine. Postoperatively he received a short course of low-dose oral opioids and subsequently developed myoclonic jerks and hyperalgesia. The opioids were discontinued and both adverse effects resolved. This case report discusses the concurrent development of myoclonus and hyperalgesia following a low dose of opioids and explores possible management options.

Clinical predictors of informative genetic testing in hypertrophic cardiomyopathy.

Giant coronary artery aneurysm (CAA) is a rare clinicopathologic entity, and there is a dearth of information regarding presentation, diagnosis, and subsequent management. We present a case of a giant aneurysm of the proximal right coronary artery (RCA) that was 1.5 × 1.5 cm with direct communication between the aneurysmal cavity and the aortic sinus. The deficit in the RCA ostium was closed with a patch of bovine pericardium. The distal communication of the aneurysm to the mid-RCA was clearly delineated and tied off. The distal RCA was grafted under bypass with a long saphenous vein. Although our case is not unique, it does represent an uncommon presentation of a rare disease process.

Background HCM is a disease characterised by otherwise unexplained hypertrophy of the myocardium, often as a result of a gene mutation. Phenotypic expression is estimated at 1 in 500 and genetic prevalence at 1 in 200. Genetic testing is used primarily to facilitate predictive testing in family members. Method A retrospective analysis of 174 consecutive HCM patients undergoing diagnostic genetic testing at a tertiary referral service in Liverpool, UK (January 2014-February 2019) was performed. Univariate and multivariate analysis was performed on pre-defined clinical characteristics. Left ventricular morphology was assessed using echocardiography and cardiac MRI. Morphology was categorised into five groups: reverse curve, sigmoid, apical, concentric and focal. Standard HCM panels were performed via Oxford and Royal Brompton genetic laboratories. Class 4 and 5 variants were deemed 'informative'.

of the intervention and 88% felt that they had adequate senior support when attending clinic. Despite this improvement only 44% of trainees felt they would attend the required numbers of clinic for their annual review of competence progression. The main reasons given for this were persistent staffing pressures on wards.