Clinical medicine (London, England)
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Implantable cardiac devices have an increasingly important role. Pacemakers remain the only effective treatment for symptomatic bradycardia; cardiac resynchronisation therapy is a proven treatment for heart failure; and implantable cardioverter defibrillators (ICD) are superior to medical therapy in prevention of sudden cardiac death. Our ageing population has led to a rising number of device implants. ⋯ Leadless devices have become a reality and represent the future of device therapy. The absence of a transvenous lead offers a significant clinical advantage because of many well established issues related to lead complications. The leadless pacemaker and subcutaneous ICD are significant new products that are currently not well recognised or understood by general physicians.
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Psoriatic arthritis (PsA) accounts for around 20% of referrals to the early arthritis clinic and presents a significant diagnostic and management challenge. Early diagnosis is important to prevent long term functional disability and to ensure optimal management of arthritis and key comorbidities. From the rheumatologist's perspective, the differential diagnosis includes rheumatoid arthritis, gout and other inflammatory arthritides. ⋯ Using this information, appropriate treatment can be planned using therapies that are effective at treating the relevant domains of disease. Despite poor data, traditional disease-modifying anti-rheumatic drugs are commonly used and have been effective in observational studies. Following tumour necrosis factor inhibitors, which have proven excellent efficacy in multiple domains of PsA, new biologics are available or in development and will improve treatment options for people with refractory PsA.
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Chronic obstructive pulmonary disease (COPD) is a major cause of disability and death in the UK but is an even greater problem in low income countries. It is assumed by many to be almost entirely attributed to smoking. ⋯ The failure of science funders to respond to the analysis of the Cooksey report, which pointed out the extreme discrepancy between the size of the problem and the paucity of research funding, represents a serious failure in science policy. The lack of urgency in the face of such a large burden of illness suggests a degree of complacency in the face of a disease that is overwhelmingly a disease of the poor.
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Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease that is highly heterogeneous in its presentation. This can pose significant challenges for physicians responsible for the diagnosis and treatment of such patients. SLE arises from a combination of genetic, epigenetic and environmental factors. ⋯ Antinuclear antibodies are the hallmark serological feature, occurring in over 95% of patients with SLE at some point during their disease. The mainstay of treatment is antimalarial drugs such as hydroxychloroquine, combined with corticosteroids and conventional immunosuppressive drugs. An increasing understanding of pathogenesis has facilitated a move towards the development of targeted biologic therapies, with the introduction of rituximab and belimumab into clinical practice.
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Samples for adrenocorticotropic hormone (ACTH) and aldosterone/renin analysis usually require rapid transport to the receiving laboratory for immediate separation and freezing. In practice, this means assessment is limited to hospital settings and many samples are rejected. We examined whether these requirements are necessary by assessing the stability of ACTH, aldosterone and renin over 48 hours in whole blood collected in serum gel and EDTA plasma from 31 participants. ⋯ Both aldosterone and renin were stable collected on serum gel at room temperature for at least 6 hours: mean change aldosterone +0.2% (95% CI -3.6 to 4.0), renin -1.9% (95% CI -7.0 to3.2). Therefore, by using appropriate preservatives, ACTH and aldosterone/renin can be measured on samples collected at room temperature and processed within 6 hours. This would facilitate outpatient and emergency room assessment of these analytes.