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in elderly patients, common bile duct stones often present atypically and co-existence with malignancy is not unusual; ampullary carcinoma has a relatively good prognosis and ERCP is a safe and effective procedure in the management of biliary obstruction.

The Royal College of Physicians state that ‘handover, particularly of temporary ‘on-call’ responsibility, has been identified as a point at which errors are likely to occur’ [1].Working a weekend on-call covering medical wards is often busy and stressful for all junior doctors, with added pressure in trying to identify patients and tasks amongst several different pieces of paper and making important care escalation.All handover sheets from a random weekend were collected and studied. Only 57% of patients listed had the minimum expected 3 patient identifiers [2] included and just 11% had any indication of escalation planning. They were also often written on scrap pieces of paper and included varying levels of relevant patient background and information.After liaison with junior doctors and the handover committee, involving senior medical clinicians, a new handover sheet was created and uploaded onto the trust intranet, to rectify some of the problems identified. Junior doctors were also educated about the changes to weekend handover.At 2 months post-introduction, another set of weekend handover sheets were collected. All medical wards used the handover sheets for documentation of patients and tasks at a weekend and inclusion of 3 patient identifiers rose to 80%. There was also a big increase noted in clinical information and background included at weekend handover and anecdotally made weekend handover easier and less stressful. There was also increased consideration of escalation planning.The handover sheet is now being rolled out trust-wide in medicine and introduced to surgical colleagues.

had a waddling gait. Clinical picture was consistent with a clinical diagnosis of LEMS rather than myositis, which was confirmed by elevated anti-VGCC antibodies and response to Acetylcholinesterase inhibitors. Results Anti-VGCC antibodies elevated at 119pM(<30).Transiently elevated CK, negative myositis autoantibodies, negative anti-MuSK antibodies, negative AChR antibodies.Although repetitive nerve stimulation did not show increment in the right ulnar CMAP after isometric muscle activation, the clinical picture was consistent with LEMS.Marked improvement to treatment with oral prednisone and pyridostigmine. Due to side effects, pyridostigmine was changed to 3,4-Diaminopyridine therapy with excellent response.Steroids were weaned off and the patient is adequately controlled on 3,4-Diaminopyridine. Conclusion Our case report shows that LEMS can arise as a result of an immune-related adverse event (irAE) to pembrolizumab; an Anti-PD-1 Monoclonal Antibody. The immune response persists after cessation of this checkpoint inhibitor medication. It is important to recognise and treat this condition early.

(Ashton C, Banham N, Needham M. Acute spontaneous spinal cord infarction: Utilisation of hyperbaric oxygen treatment, cerebrospinal fluid drainage and pentoxifylline. Diving and Hyperbaric Medicine. 2020 December 20;50(4):325–331. doi: 10.28920/dhm50.4.325-331. PMID: 33325011.) Introduction: Spinal cord infarction (SCI) is a potentially devastating disorder presenting with an acute anterior spinal artery syndrome, accounting for an estimated 1% of stroke presentations. Aetiologies include aortic surgical complications, systemic hypotension, fibrocartilaginous embolism and vascular malformations. Diagnosis is clinical combined with restriction on diffusion-weighted magnetic resonance imaging (MRI). There are no treatment guidelines for non-perioperative cases although there is limited literature regarding potential therapies, including hyperbaric oxygen treatment (HBOT) and cerebrospinal fluid (CSF) drainage. We describe 13 cases of acute SCI, five receiving HBOT, and three also receiving pentoxifylline and drainage of lumbar CSF. Methods: Data for all patients with MRI-proven SCI at Fiona Stanley Hospital from 2014–2019 were reviewed. Results: Thirteen patients, median age 57 years (31–74), 54% female, were identified. Aetiologies: two fibrocartilaginous emboli; seven likely atherosclerotic; two thromboembolic; two cryptogenic. All presented with flaccid paraplegia except one with Brown-Sequard syndrome. Levels ranged from C4 to T11. Five patients received HBOT within a median time of 40 hours from symptom onset, with an average 15 treatments (10−20). Three of these received triple therapy (HBOT, pentoxifylline, CSF drainage) and had median Medical Research Council manual muscle testing power of 5, median modified Rankin Score (mRS) of 1 and American Spinal Injury Association (ASIA) score of D on discharge, compared with 2 power, mRS 3.5 and ASIA B in those who did not. Conclusions: SCI can be severely disabling. Triple therapy with pentoxifylline, CSF drainage and HBOT may reduce disability and further prospective trials are required.