Internal medicine journal
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Internal medicine journal · Jan 2010
Case ReportsEnd-of-life decision-making in individuals with locked-in syndrome in the acute period after brainstem stroke.
Locked-in syndrome (LIS) is commonly associated with a poor prognosis, particularly if the aetiology is stroke. Dealing with individuals with LIS and a poor prognosis raises the issue of introducing end-of-life discussions with the patient and/or family in the acute period of the illness. Existing literature regarding LIS provides little guidance about end-of-life decision-making in the acute management phase. ⋯ Despite the severity of their conditions, in neither case were end-of-life discussions well tolerated by the family in the weeks following admission. We suggest that LIS patients and their families, who have chosen to persist with full medical management after diagnosis of LIS, should be provided with sufficient time to adjust to the catastrophic changes that have occurred before further end-of-life discussions are pursued. Education and support are likely to be highly beneficial in the acute period post stroke as they allow the patient and family to develop a realistic understanding of the likely outcomes of their decisions.
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Internal medicine journal · Jan 2010
ReviewQuality of drug prescribing in older patients: is there a problem and can we improve it?
Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. ⋯ A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.
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Internal medicine journal · Jan 2010
Case ReportsOverdose with modified-release paracetamol results in delayed and prolonged absorption of paracetamol.
A modified-release formulation of paracetamol is currently available in Australasia and marketed under a number of different trade names. These include: Panadol Osteo, Panadol Extend Tablets, and Duatrol SR. We report four cases of intentional overdose with this formulation resulting in delay to peak plasma paracetamol concentrations and prolonged paracetamol absorption. ⋯ Treatment with NAC should continue if either concentration falls above the paracetamol treatment nomogram line. With massive ingestions of this paracetamol formulation (>50 grams) plasma concentrations may be elevated for several days and prolonged treatment with NAC is recommended. When modified-release paracetamol overdose is suspected a clinical toxicologist or Poisons Information Centre should be consulted to help guide management decisions.
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Internal medicine journal · Jan 2010
Letter Case ReportsPictorial evolution of bilateral adrenal haemorrhage.