Clinical medicine (London, England)
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Insulin therapy is important in many patients with diabetes, but the UK National Diabetes Inpatient Audit (NaDIA) suggests that insulin therapy in hospital is poorly monitored and managed. Although most hospitals should have access to an inpatient diabetes specialist team, it is important for the non-specialist clinician to be aware of the indications for insulin therapy, types of insulin and insulin regimens, methods of adjusting insulin doses and the need for care with insulin prescribing. Here, we demystify issues around insulin therapy.
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Gout, classically affecting the first metatarsal joints, knees, fingers and ears, is seldom thrown out as a differential when a patient complains of lower back pain. Symptoms presented by patients with spinal gout may be non-specific and varied; at times, the only clue being that the patient has a previous history of gout. ⋯ Therefore, it is vital for the treating physician to keep an open mind and consider spinal gout as a diagnosis once other sinister causes such as osteomyelitis have been ruled out. This greatly reduces the morbidity associated with late treatment of spinal gout.
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The differential diagnosis of haematological abnormalities, such as leucocytosis, erythocytosis, thrombocytosis or indeed anaemia, is wide and disarming. Here we report on significant updates in the differential diagnosis of erythrocyosis and thrombocytosis presenting a simplified schema for the clinician. We then move to discuss significant advances in this field which have followed a series of key molecular findings, most specifically those affecting the JAK/STAT pathway.
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The purpose of modern radiotherapy is to deliver a precise high dose of radiation which will result in reproductive death of the cells. Radiation should transverse within the tumour volume whilst minimising damage to surrounding normal tissue. Overall 40% of cancers which are cured will have received radiotherapy. ⋯ Brachytherapy enables very high radiation doses to be delivered by the direct passage of a radiation source through or within the tumour volume and similar results can be achieved using rotational stereotactic X-ray beam techniques. Protons have the characteristics of particle beams which deposit their energy in a finite fixed peak at depth in tissue with no dose beyond this point - the Bragg peak. This has advantages in certain sites such as the spine adjacent to the spinal cord and particularly in children when the overall volume of tissue receiving radiation can be minimised.
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An 85-year-old man presented to hospital as an emergency having difficulties with swallowing and speech. In the emergency department, he was assessed as having acute onset dysphagia and dysarthria in keeping with an acute stroke. ⋯ Myasthenia gravis is an uncommon disorder but it is more common in the elderly. This case provides key learning points, particularly highlighting the value of prompt, accurate clinical assessment and the importance of adhering to the clinical diagnostic formulation.