Clinical medicine (London, England)
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Historical Article
Lessons of the month 1: Learning from Harvey; improving blood-taking by pointing the needle in the right direction.
The taking of blood for diagnostic purposes is a frequent cause of difficulty for physicians. In patients with intact visible or palpable large veins, such as those often seen in the antecubital fossa, a needle or cannula entering from any direction will usually be rewarded with any quantity of blood. ⋯ Failure to take blood is very commonly because of failure to appreciate the direction of flow of venous blood up the arm, and the ubiquitous presence of valves in the veins, both aspects of the circulation clearly described by William Harvey nearly 4 centuries ago. This paper encourages more frequent success with phlebotomy by remembering Harvey's work and pointing the needle in the right direction; this is not always towards the heart.
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Decisions on how and when to treat an abdominal aortic aneurysm involve a number of clinicians; interventional radiologists and vascular surgeons assess the technical ability to repair the aneurysm. Patients' fitness and past medical history is assessed to estimate their short- and long-term survival with or without surgery. Most importantly the patients' personal preference for treatment must be identified. Getting a patient to share what matters most to them requires shared decision making.
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Observational Study
The impact of misdiagnosing Bell's palsy as acute stroke.
Idiopathic Bell's palsy can lead to a serious and, sometimes permanently, disfiguring and emotionally challenging facial palsy. Early diagnosis and treatment with corticosteroids are important, as they significantly improve recovery rates. ⋯ We reviewed all patients referred urgently to our hospital with facial weakness and discharged with a diagnosis of Bell's palsy, to explore whether clinicians were confident in making this diagnosis at initial assessment and, if not, how often they sought a specialist opinion. Furthermore, we assessed the impact of its over-investigation and mistreatment on healthcare resources and the patients.
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In this article, we review the evidence underpinning the broader prehabilitation concept and the target behavioural and lifestyle risk factors including their perioperative impact and evidence for prehabilitation intervention. We also identify principles for delivering prehabilitation in practice, alongside lessons for the perioperative setting from well-established allied interventions; cardiac and pulmonary rehabilitation.
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The perioperative period extends from the moment of contemplation of surgery through to recovery at home. Patients on a surgical pathway will experience multiple transition points in their care. ⋯ This article reviews best practice and guidance on handover of care throughout the perioperative period. We will look at models of transition of care beyond the hospital environment and how better use of community resources can smooth the transition of care out of hospital for ongoing rehabilitation.