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The risk of pancytopenia during leflunomide therapy appears to be increased when the drug is combined with methotrexate and in older patients. Onset may be delayed, and ongoing monitoring of blood counts is essential.

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A 58-year-old woman presented with a 2-week history of acute dyspnea in the setting of subtherapeutic warfarin anticoagulation (international normalized ratio, 1.7 on admission) with a history of previous St. Jude bileaflet aortic valve replacement (AVR) 5 years previously. Transthoracic echocardiography revealed severe elevation of the prosthetic aortic transvalvular gradient (peak velocity, 5 m/s; peak gradient, 125 mm Hg) with severe eccentric aortic regurgitation. The morphology of the prosthetic aortic valve was not clearly visualized secondary to an acoustic shadow from the metallic prosthesis. The patient was referred to cardiac computed tomography (CT) for further evaluation of prosthetic dysfunction and to exclude coronary artery disease in case surgical intervention was required.Dual-source cardiac CT (Definition, Siemens Healthcare, Erlangen, Germany) was able to demonstrate the underlying cause of the prosthetic valve dysfunction. The AVR was obstructed by acute thrombus ( Figure 1A) with fixation of the posterior leaflet with an abnormal opening angle of 80° ( Figure 2A and Movies IA and IIA in the online-only Data Supplement). This contributed to the significantly elevated transvalvular gradient and eccentric aortic regurgitation. The anterior leaflet maintained normal mobility. No significant coronary artery disease was detected on cardiac CT angiography. Normally functioning St. Jude AVR should have a maximal opening angle of up to 10°in systole and a closure angle of 120°to 130°in diastole between the 2 leaflets.The patient received successful thrombolysis treatment with recombinant tissue-type plasminogen activator (75 mg over 3 hours) with favorable outcome. A repeat cardiac CT within 24 hours showed dissolution of the thrombus and return of normal prosthetic valve function with a full range of leaflet mobility ( Figures 1B and 2B and Movies IB and IIB in the online-only Data Supplement).

Background Ordering of computed tomography (CT) scans needs to consideration of diagnostic utility as well as resource utilisation and radiation exposure. Several factors influence ordering decisions, including evidence-based clinical decision support tools to rule out serious disease. The aim of this qualitative study was to explore factors influencing Emergency Department (ED) doctors’ decisions to order CT of the head or cervical spine. Methods In-depth semi-structured interviews were conducted with purposively selected ED doctors from two affiliated public hospitals. An interview tool with 10 questions, including three hypothetical scenarios, was developed and validated to guide discussions. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo Release 1.3 to facilitate coding and thematic analysis. Results In total 21 doctors participated in semi-structured interviews between February and December 2020; mean interview duration was 35 min. Data saturation was reached. Participants ranged from first-year interns to experienced consultants. Five overarching emerging themes were: 1) health system and local context, 2) work structure and support, 3) professional practices and responsibility, 4) reliable patient information, and 5) holistic patient-centred care. Mapping of themes and sub-themes against a behaviour change model provided a basis for future interventions. Conclusions CT ordering is complex and multifaceted. Multiple factors are considered by ED doctors during decisions to order CT scans for head or c-spine injuries. Increased education on the use of clinical decision support tools and an overall strategy to improve awareness of low-value care is needed. Strategies to reduce low-yield CT ordering will need to be sustainable, sophisticated and supportive to achieve lasting change.