The Medical journal of Australia
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Intractable disputes about withholding and withdrawing life-sustaining treatment from adults who lack capacity are rare but challenging. Judicial resolution may be needed in some of these cases. A central concept for judicial (and clinical) decision making in this area is a patient's "best interests". ⋯ There is an emerging Supreme Court jurisprudence that sheds light on when life-sustaining treatment will, or will not, be judged to be in a patient's best interests. Treatment that is either futile or overly burdensome is not in a patient's best interests. Although courts will consider patient and family wishes, they have generally deferred to the views of medical practitioners about treatment decisions.
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While the evidence base for management of acute coronary syndrome (ACS) is extensive, some subgroups have been underrepresented or excluded from relevant clinical trials. These subgroups - such as women, older people, diabetic patients and Indigenous Australians - present clinical challenges for which there is limited evidence to guide optimal therapy. Women may have a different pattern of presentation, with potential for delays in diagnosis and worse outcomes in ST-elevation myocardial infarction, but there is no evidence that treatments affect them differently from men. ⋯ Coronary artery bypass grafting is preferred to percutaneous coronary intervention for patients with diabetes and multivessel disease, although the latter is reasonable in single-vessel disease. Indigenous patients have a high prevalence of coronary disease, with more frequent coronary events at a young age, a heavy load of risk factors and poor outcomes after ACS. The complex sociocultural barriers to treatment are yet to be addressed adequately.
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To determine the likely impact of aggression from internal sources (co-workers) and external sources (patients, patients' relatives or carers and others) on Australian medical clinicians in the previous 12 months. ⋯ The likely impact of workplace aggression on clinician wellbeing may extend to adverse consequences for care quality, safety and access. More concerted efforts to prevent and minimise workplace aggression are required.
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About half of all patients who experience an acute coronary syndrome (ACS) in Australia have their conditions managed non-invasively - that is, they do not undergo coronary angiography and revascularisation in hospital. ACS patients whose conditions are managed non-invasively may not receive the same level of evidence-based care as those who receive coronary revascularisation. This article reviews the optimal pharmacological management of ACS managed non-invasively. ⋯ Use of β-adrenergic blockers is recommended in most guidelines, but the clinical trials to support this recommendation were performed more than 30 years ago, and routine long-term use may not be relevant to modern treatment, except when there is cardiac failure or left ventricular dysfunction. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are also widely recommended, but the evidence for benefit is stronger when there is left ventricular dysfunction. Calcium-channel blockers, nitrates, antiarrhythmic drugs, digoxin and diuretics do not improve outcomes in post-ACS patients.
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To determine the incidence of surfboard-related eye injuries (SREIs) in New South Wales in 1 year. ⋯ This study confirms that surfing carries a small risk of eye trauma and helps to describe and quantify SREIs. A fifth of the SREIs we report were severe. Surfboard modification and protective eyewear may help reduce the risk of SREIs.