Clin Med
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Patients who remain unconscious and unaware after a brain insult challenge healthcare. Clinicians are faced with a clinical situation often outside their usual experience. ⋯ And people, especially family and friends, are faced with moral, legal and philosophical questions that have no easy answers. This conference launched national guidelines that should assist clinical teams and organisations, and should ensure that all patients and families receive a good quality service.
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This paper reports on a study that aimed to assess the inter-rater agreement of observable neurological signs in the upper and lower limbs (eg inspection, gait, cerebellar tests and coordination) and elicitable signs (eg tone, strength, reflexes and sensation). Thirty patients were examined by two neurology doctors, at least one of whom was a consultant. The doctors' findings were recorded on a standardised pro forma. ⋯ Almost perfect agreement was seen for cerebellar signs and inspection (a combination of speed of movement, muscle bulk, wasting and tremor); substantial agreement for strength, gait and coordination; moderate agreement for tone and reflexes; and only fair agreement for sensation. The inter-rater agreement is therefore better for observable neurological signs than for elicitable signs, which may be explained by the additional skill and cooperation required to elicit rather than just observe clinical signs. These findings have implications for clinical practice, particularly in telemedicine, and highlight the need for standardisation of the neurological examination.
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Decisions about percutaneous endoscopic gastrostomy (PEG) can be clinically and ethically challenging, particularly when patients lack decision-making capacity. As the age of the UK population rises, with the associated increase in prevalence of dementias and neurodegenerative diseases, it is becoming an increasingly important issue for clinicians. The recent review and subsequent withdrawal of the Liverpool Care Pathway highlighted feeding as a particular area of concern. ⋯ The second largest group was those who had had a stroke or brain haemorrhage (13%). Twenty-eight per cent of patients had no, or uncertain, decision-making capacity on at least one occasion during decision-making. There are reflections on the role of a multidisciplinary team in the process of decision-making for these complex patients.
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The adequate supervision of trainee doctors seeing ward referrals is critical to the quality of patient care and medical training. This survey assessed the level and nature of supervision of trainees in neurology and comparable specialities. 123 neurology specialty registrars from nine deaneries across the UK and 81 dermatology, rheumatology and infectious disease specialty registrars from the London deanery completed the survey. ⋯ The remaining first year neurology and non-neurology registrars reported being primarily supervised by discussing cases with consultant (62% and 37% respectively) or being asked to contact a consultant if help was needed (35% and 42% respectively). The lack of adequate supervision of junior trainees seeing ward referrals has significant implications for both patient safety and training.