Clinical medicine (London, England)
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Fluid management is an essential competency for hospital doctors, but previous studies suggest junior clinicians lack the necessary 'knowledge' and 'prescription skills' to complete this task, resulting in preventable morbidity and mortality. In this study, preregistration (n=146), core (n=66) and specialty (n=133) medical trainees and general medical consultants (n=11) completed a structured questionnaire exploring fluid management training, confidence, serious adverse event experience and a 20-item fluid management 'knowledge' test. Results were compared with those of intensive care consultants (n=20). ⋯ Foundation year trainees scored 7 (IQR 5-8), core medical trainees scored 9 (IQR 6-10), specialist registrars scored 8 (IQR 6-10) and general medical consultants scored 8 (IQR 6-12) compared with the intensive care consultant score of 16 (IQR 14-16). Although weakly correlated, fluid management 'confidence' appeared higher than 'knowledge' tests would justify. These results suggest that physicians' fluid management knowledge is inadequate, including that of senior colleagues, compounded by poor training and failure to learn from serious adverse events.
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The aim was to determine if the 17 June 2014 Tracey judgment regarding 'do not attempt cardiopulmonary resuscitation' decisions led to increases in the rate of in-hospital cardiac arrests resulting in a resuscitation attempt (IHCA) and/or proportion of resuscitation attempts deemed futile. ⋯ The IHCA rate increased immediately after the Tracey judgment while the proportion of resuscitation attempts deemed futile decreased. The precise mechanisms for these changes are unclear.
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An electronic resuscitation system, implemented in 2015, within electronic patient records (EPR) at King's College Hospital NHS Foundation Trust was studied, aiming to review and improve decision documentation and communication. ⋯ Changes to the process and trust-wide education resulted in more robust documentation and communication.
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We discuss the case of a 22-year-old man who presented with paraesthesia, reduced sensation and weakness in his limbs. Examination was in keeping with a myeloneuropathy. Initial investigations including vitamin B12 were unremarkable but magnetic resonance imaging of the spinal cord showed subacute combined degeneration. ⋯ Nitrous oxide use is prevalent and can have significant health effects. Many adverse effects are mediated through inactivation of vitamin B12 and can be detected by elevated homocysteine and methylmalonic acid levels. Early identification and prompt treatment are important to support neurological recovery.
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Non-alcoholic fatty liver disease (NAFLD) accounts for 10-15% of orthotopic liver transplants (OLTs) in the UK. Index presentations with cirrhotic decompensation represent missed opportunities for preventive treatment leaving OLT or palliation as the only options. We retrospectively reviewed patient records for all NAFLD patients undergoing assessment for OLT between January 2003 and December 2017. ⋯ Cirrhosis was not suspected at the time of referral to hospital in 24.7% of patients subsequently assessed for OLT. Most patients undergoing assessment for OLT for NAFLD had decompensated cirrhosis at their first diagnosis of chronic liver disease. These data highlight the plight of patients with NAFLD cirrhosis in whom chronic liver disease is diagnosed late.