Clinical medicine (London, England)
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After 60 years in which warfarin has been the only practical oral anticoagulant, a number of new oral anticoagulants are entering practice. These drugs differ in a several important respects from warfarin; most notably they have a reliable dose-response effect which means they can be given without the need for monitoring. ⋯ Large trials have established their non-inferiority to warfarin in a number of indications and in some cases their superiority. To date they have been licensed for prophylaxis following high risk orthopaedic procedures, non-valvular atrial fibrillation and treatment of venous thromboembolism, but is not clear that they will supplant warfarin in all areas.
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Stroke is an important cause of death and disability throughout the world. Most strokes are ischaemic, caused by thrombotic or embolic occlusion of blood vessels. The advent of thrombolysis for acute ischaemic stroke has revolutionised the treatment of acute stroke in the developed world. ⋯ Clinical stroke services need to ensure that all acute stroke patients can be scanned, treated and admitted to stroke units without delay. Future research needs to address the prevention and better management of complications, such as secondary intracerebral haemorrhage and angioedema. In addition, the evidence base for direct intra-arterial intervention such as thrombectomy needs to be established.
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Eosinophilic oesophagitis is a clinico-pathologic diagnosis that describes patients with dysphagia (intermittent or continuous), food bolus obstruction or regurgitation, where endoscopy and biopsy reveals high concentrations of eosinophils in the lining of the oesophagus. At endoscopy, the presence of rings (trachealisation), furrows, micro-abscesses and strictures may be noted, but sometimes the appearance is normal. ⋯ It is important for all general physicians to recognise this and make an accurate diagnosis in order to give specific treatment. This may involve topical steroids, leukotreine D4 antagonists, dietary exclusions and dilatations.
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Cardiovascular magnetic resonance (CMR) is a noninvasive imaging tool with high spatial resolution in the absence of ionising radiation. CMR imaging is routine in the functional assessment of coronary lesions and is widely held as the gold standard in myocardial viability imaging. ⋯ In the near future, CMR fibrosis imaging may serve as a risk stratification tool for the cardiomyopathies; and the ability to assess interstitial fibrosis may advance this role into other disease processes. Novel methods of tissue characterisation and emerging technical advances present new avenues for this modality, securing its place as the noninvasive imaging tool of the future.