Brit J Hosp Med
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Restless legs syndrome describes a curious need to stretch and move in response to an unpleasant feeling in the legs. For most people who have this, as they are drifting off to sleep there is a twitch of the toe, foot and ankle followed by another and then another. The limb movements are strikingly periodic and are described as such by frustrated bed partners. ⋯ This article outlines the diagnostic criteria, medication and comorbidities that modify symptoms, the impact of restless legs syndrome on health, and symptomatic management. Several licensed therapies are effective but the dopamine agonists in particular can cause challenging side effects and paradoxically worsen symptoms over time. Case histories are reviewed to guide physicians.
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Management of anticoagulation has become a hot topic in the last decade. Health-care professionals are encountering increasing number of patients diagnosed with a thromboembolic episode, probably as a result of heightened awareness. ⋯ However, the use of anticoagulants for both treatment and prophylaxis of thrombosis can pose a challenge in individuals who are obese. There are no detailed studies in this area and as such the dosing and monitoring of anticoagulants in these individuals can be problematic.
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It is important for physicians to be aware of stroke warning syndromes because, although rare, there is a high associated risk of subsequent ischaemic infarction. Stroke warning syndromes present as stereotypical, recurrent transient episodes of focal neurological deficit, in the absence of cortical signs, occurring within a short period of time. They are broadly divided into two main subtypes, based on vascular territory: capsular warning syndrome and pontine warning syndrome. ⋯ Atherosclerotic disease involving small perforating arteries in the anterior circulation (e.g. lenticulostriatal arteries) gives rise to capsular warning syndrome and subsequent risk of capsular infarcts. Conversely, involvement of the posterior circulation pontine perforator arteries gives rise to pontine warning syndrome, which can result in paramedian pontine infarcts. Although the evidence is limited, recommended treatment modalities include permissive hypertension, intravenous recombinant tissue plasminogen activator, dual antiplatelet therapy and statins.
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Epidural analgesia is a key component in the management of inpatient pain relief, particularly in surgical and trauma patients, and those with comorbidities. When used appropriately epidurals can decrease a patient's opiate consumption, as well as reducing the risk of adverse cardiorespiratory outcomes. ⋯ This article demystifies the epidural for hospital clinicians, looking at the anatomy and pharmacology, helping to identify patients who may benefit from epidural analgesia, highlighting some common pitfalls and questions posed by nursing staff, and providing a framework via which junior clinicians can detect, manage and appropriately escalate epidural-related problems and complications. Epidural analgesia is an invasive and high-risk intervention; as such it should always be managed by a multidisciplinary team, including anaesthesia and acute pain services.
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The impact of hospital-acquired pneumonia and the pressure to reduce unnecessary antibiotic prescribing has lead to the publication of prescribing guidelines from the National Institute for Health and Care Excellence. This editorial gives an overview of the guidelines and emphasises the need for more high-quality evidence to inform decision making in this group of patients.