Clinical medicine (London, England)
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Falls among inpatients are the most frequently reported safety incident in NHS hospitals. 30-50% of falls result in some physical injury and fractures occur in 1-3%. No fall is harmless, with psychological sequelae leading to lost confidence, delays in functional recovery and prolonged hospitalisation. Yet falls are not true accidents and there is evidence that a coordinated multidisciplinary clinical team approach can reduce their incidence. ⋯ The implementation of complex multiprofessional interventions is challenging and successful schemes seek to nurture a culture of vigilant safety consciousness in all staff at the clinical interface. Strong leadership and organisational oversight help to combine this cultural evolution with relevant evidence and rigorous measurement of performance in order to improve patient safety. The results of national audit suggest that NHS acute hospitals could do more to reduce the incidence of falls among inpatients.
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Physicians responsible for the care of patients with heart failure due to left ventricular systolic dysfunction have access to a broad range of evidence-based treatments that prolong life and reduce symptoms. In spite of the significant progress made over the last four decades, there is an ongoing need for novel therapies to treat a condition that is associated with stubbornly high morbidity and mortality. ⋯ The recently published National Institute for Health and Care Excellence guidelines for the management of acute heart failure and plans to introduce best practice tariffs bring into focus the need for well-organised, multidisciplinary care. We discuss the challenges involved in developing and delivering a specialist service that meets the needs of a growing population of patients living with heart failure.
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Peripartum cardiomyopathy reflects the presence of cardiac failure in the absence of determinable heart disease and occurs in late third trimester of pregnancy or up to 6 months postpartum. A full understanding of pathophysiological mechanisms is lacking, but excess prolactin levels, haemodynamic alterations, inflammation and nutritional deficiencies have all been implicated. Its clinical presentation has distinct overlap with physiological alterations in healthy pregnancy and this presents a diagnostic challenge. ⋯ Pharmacotherapy is broadly aligned with established guidelines for cardiac failure, but specific therapies are indicated for treatment of clinical sequelae. Moreover, an individualistic approach is required based on clinical context to manage delivery. Further research appears imperative to optimise management strategies and reduce disease burden.
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Life-sustaining and life-improving surgical interventions are increasingly available to older, frailer patients, many of whom have multimorbidity. Physicians can help support perioperative multidisciplinary teams with assessment and preoperative optimisation of physiological reserve, comorbidities and associated geriatric syndromes. Similar structured support can be useful in the postoperative period where older patients are at increased risk of delirium, medical complications, increased functional dependency and where discharge planning can prove more difficult than in younger cohorts. ⋯ Perioperative comprehensive geriatric assessment has been explored in other surgical disciplines and procedures and, where evaluated, has been associated with improved outcomes. The need to support older patients with frailty undergoing surgery exceeds the capacity of specialist geriatricians. Other groups of healthcare professionals need to nurture the core competencies to support this group perioperatively.