Clin Med
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Three documents have been produced in an attempt to increase the number of organs available for transplant: a National Institute for Health and Clinical Excellence (NICE) clinical guideline, a British Medical Association (BMA) report and a Welsh Government white paper. All three are ethically flawed: NICE and the BMA recommend that whenever there is intention to withdraw life-sustaining treatment and death is expected, patients should instead be stabilised to assess for donation. ⋯ Regarding consent, the BMA and Welsh Government recommend an 'opt-out' policy, but consent in law requires information and cannot be 'presumed' or 'deemed' on the basis of failure to express or register 'opting out'. The language of all three proposals is manipulative, and patient trust may be undermined because the doctor's attention must move from the interests of the patient to those of the unknown organ recipients.
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Hepatic cirrhosis secondary to excess alcohol consumption is increasing in incidence, and these patients can develop ataxia secondary to direct toxic effects of alcohol on the cerebellum. However, it is important to remain vigilant for other causes of an unsteady gait, including space-occupying lesions and medications, such as phenytoin. Patients with hypoalbuminaemia, such as those with cirrhosis, are more prone to developing toxic effects from phenytoin, as this Lesson describes. Therefore, dose adjustments might be necessary.
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Despite many advances in treatment, amyloid heart disease still portends a poor outcome. Around 50% of patients will suffer a sudden arrhythmic death. As in the case described, this may happen before the patient has received sufficient treatment to curtail the amyloidogenic process.
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Traditionally, clinician scientists in the UK have been trained by a sequence of medical school, junior hospital posts, MRCP and research leading to a PhD. Thereafter they undertake a mixture of more senior middle-grade jobs leading to senior or lecturer consultant posts and beyond. ⋯ The first graduates are now attaining chairs. Here, we review the experience of such a course in the UK context.