Brit J Hosp Med
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Polypharmacy and multimorbidity are both currently rising. The number of medicines taken is the single biggest predictor of adverse drug events. ⋯ Multiple international evidence-based guidelines are emerging to promote discontinuation of high-risk medications, and use of alternative medical and non-pharmacological management. This review outlines the evidence base behind deprescribing, and suggests some pragmatic approaches to decision making around medication review.
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Epidural analgesia is a key component in the management of inpatient pain relief, particularly in surgical and trauma patients, and those with comorbidities. When used appropriately epidurals can decrease a patient's opiate consumption, as well as reducing the risk of adverse cardiorespiratory outcomes. ⋯ This article demystifies the epidural for hospital clinicians, looking at the anatomy and pharmacology, helping to identify patients who may benefit from epidural analgesia, highlighting some common pitfalls and questions posed by nursing staff, and providing a framework via which junior clinicians can detect, manage and appropriately escalate epidural-related problems and complications. Epidural analgesia is an invasive and high-risk intervention; as such it should always be managed by a multidisciplinary team, including anaesthesia and acute pain services.
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Restless legs syndrome describes a curious need to stretch and move in response to an unpleasant feeling in the legs. For most people who have this, as they are drifting off to sleep there is a twitch of the toe, foot and ankle followed by another and then another. The limb movements are strikingly periodic and are described as such by frustrated bed partners. ⋯ This article outlines the diagnostic criteria, medication and comorbidities that modify symptoms, the impact of restless legs syndrome on health, and symptomatic management. Several licensed therapies are effective but the dopamine agonists in particular can cause challenging side effects and paradoxically worsen symptoms over time. Case histories are reviewed to guide physicians.
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Vitamin D deficiency has become an increasing focus of clinical interest, especially in understanding its associations with obesity in adults. The pathological associations linking the two appear to demonstrate complex cellular inflammatory, hormonal and genetic pathways. Enhanced understanding at both microcellular and clinical levels will help clarify the role of obesity in the development of vitamin D deficiency.
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Hypoxaemia is a common presentation in critically ill patients, with the potential for severe harm if not addressed appropriately. This review provides a framework to guide the management of any hypoxaemic patient, regardless of the clinical setting. Key steps in managing such patients include ascertaining the severity of hypoxaemia, the underlying diagnosis and implementing the most appropriate treatment. ⋯ Early critical care team involvement is a key part of this pathway. Specialist treatments for severe hypoxaemia can only be undertaken on an intensive care unit and this field is developing rapidly as trial results become available. It is important that each new scenario is approached in a structured manner with an open diagnostic mind and a clear escalation plan.