Clinical medicine (London, England)
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Care of people in their last days of life should be based on compassion, respect and, wherever possible, on research evidence. Previously the Liverpool Care Pathway attempted to facilitate this but it was withdrawn after an independent government report found that its uncritical implementation could lead to poor care. This Concise Guideline overviews NICE Clinical Guideline (NG31), which addresses: recognising dying; communication and shared decision making; maintaining hydration; and pharmacological symptom control, including anticipatory prescribing. ⋯ Specific areas where practices will need to reflect the individualised approach to care are highlighted. Limitations of the guideline are discussed. Potential barriers to implementation include need for further training and 24/7 availability of specialist support to front-line clinicians.
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Randomized Controlled Trial
Randomised controlled trial of GP-led in-hospital management of homeless people ('Pathway').
Homeless people have complex problems. GP enhanced care (Pathway) has shown benefits. We performed a randomised, -parallel arm trial at two large inner city hospitals. ⋯ The proportion of people sleeping on the streets after discharge was 14.6% in the standard care arm and 3.8% in the enhanced care arm (p=0.034). The quality-of-life cost per quality-adjusted life-year was £26,000. The Pathway approach doesn't alter length of stay but improves quality of life and reduces street -homelessness.
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There is no national NHS tariff to fund services for patients experiencing long-term bowel and nutritional problems after cancer treatment. In this paper, we report the clinical characteristics and outcomes of patients referred to our service and the estimated cost of a completed episode of care. Patient characteristics, symptom severity, investigations, diagnoses, number of clinic visits and referrals elsewhere were recorded in a prospective cohort study. ⋯ A median of three visits were required and all commonly reported gastrointestinal symptoms improved by discharge. The mean episode of care per patient was costed at £1,563. Effective amelioration of chronic gastrointestinal toxicity after cancer treatment costs substantially less than treating the cancer in the first place and requires an NHS tariff.
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Clinical Trial
An in vitro analysis of the effect of acidosis on coagulation in chronic disease states - a thromboelastograph study.
Thrombosis is a complication of many chronic illnesses. Chronic obstructive pulmonary disease (COPD) and diabetes mellitus are common medical conditions frequently associated with a hypercoagulable state. Acidaemia has been shown to reduce coagulation. ⋯ All other coagulation and TEG parameters failed to show evidence of association (p>0.05). In the two models of non-haemorrhagic acidosis investigated, coagulation was not altered by the changes in pH. More work is needed to understand the complex relationship between factors affecting coagulation in individual disease processes.
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Case Reports
Lesson of the month 2: Houssay phenomenon - hypopitutarism leading to remission of diabetes.
Because of a pituitary insult and the subsequent loss of counter-regulatory hormones, individuals can experience increased sensitivity to insulin, hypoglycaemia or even complete amelioration of diabetes; this is known as the Houssay phenomenon. Severe dehydration following diarrhoea can lead to pituitary infarction causing hypopituitarism. ⋯ Physicians should keep this possibility in mind while treating hypoglycaemia in stable diabetic individuals. Judicious supplementation of deficient hormones is of utmost importance.