Clin Med
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The NHS, yet again, is in transition with an emphasis on groups of general practitioners (GPs) (clinical commissioning groups) making decisions on which specialist services should be chosen for patients requiring referral from primary care. It is an area of new terminology with a new language and further change for all working in the NHS and the all-important interface between primary and secondary care, and its impact on teamwork. There are many drivers including choice, efficiency, franchising of services, coordination and leadership in an enormous organisation, but not least reducing costs and keeping to a budget. There are many logistical issues and ethical anxieties, and only time will inform patients, practitioners, stakeholders and politicians as to its success.
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The misdiagnosis of MND (particularly of the ALS phenotype), is uncommon. Atypical presentations, particularly of focal onset and with pure LMN or UMN signs, present a more difficult diagnostic challenge, although perhaps reassuringly, treatable mimics are rare. A working knowledge of potential alternative conditions and MND diagnostic pitfalls should help to reduce the misdiagnosis rate, particularly if the key points are considered.
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Chronic stable angina is the most common manifestation of ischaemic heart disease in the developed world and is associated with impaired quality of life and increased mortality. The pathogenesis of stable angina is complex and often, albeit not always, involves flow-limiting epicardial coronary artery stenoses (atheromatous plaques) that reduce the ability of the coronary circulation to deliver appropriate blood supply to the myocardium. The coronary microcirculation can also play an important role. ⋯ These novel agents have specific mechanisms of action and fewer side effects compared to conventional drugs. The combined use of traditional and novel treatments is likely to increase the proportion of patients who are managed successfully with medical therapy alone. This article briefly reviews recent advances in the pharmacological management of chronic stable angina pectoris, highlighting how an understanding of the prevailing pathogenic mechanisms in the individual patient can aid appropriate selection of therapeutic strategies and improve clinical outcome.
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This overview of systematic reviews (SRs) aims to evaluate critically the evidence regarding the adverse effects of herbal medicines (HMs). Five electronic databases were searched to identify all relevant SRs, with 50 SRs of 50 different HMs meeting our inclusion criteria. Most had only minor weaknesses in methods. ⋯ Moderately severe adverse effects were noted for 15 HMs: Pelargonium sidoides, Perna canaliculus, Aloe vera, Mentha piperita, Medicago sativa, Cimicifuga racemosa, Caulophyllum thalictroides, Serenoa repens, Taraxacum officinale, Camellia sinensis, Commifora mukul, Hoodia gordonii, Viscum album, Trifolium pratense and Stevia rebaudiana. Minor adverse effects were noted for 31 HMs: Thymus vulgaris, Lavandula angustifolia Miller, Boswellia serrata, Calendula officinalis, Harpagophytum procumbens, Panax ginseng, Vitex agnus-castus, Crataegus spp., Cinnamomum spp., Petasites hybridus, Agave americana, Hypericum perforatum, Echinacea spp., Silybum marianum, Capsicum spp., Genus phyllanthus, Ginkgo biloba, Valeriana officinalis, Hippocastanaceae, Melissa officinalis, Trigonella foenum-graecum, Lagerstroemia speciosa, Cnicus benedictus, Salvia hispanica, Vaccinium myrtillus, Mentha spicata, Rosmarinus officinalis, Crocus sativus, Gymnema sylvestre, Morinda citrifolia and Curcuma longa. Most of the HMs evaluated in SRs were associated with only moderately severe or minor adverse effects.
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Parkinson's disease is a common, progressive, debilitating disease with substantial physical, psychological and social implications. Pharmacological management is complex and should be individualised according to the needs of the patient. In early disease, treatment is generally highly effective, but medication becomes increasingly inadequate in controlling motor fluctuations and dyskinesias as the disease progresses. ⋯ Gene-therapy trials in progress rely on the viral vectors used to deliver the enzymatic machinery required for dopamine synthesis to the striatum. As PD progresses, adequate control of motor symptoms depends increasingly on continuous drug delivery, and greater physiological stimulation of dopamine receptors may help to prevent the development of LIDs and motor fluctuations. Efforts thus are afoot to develop better delivery systems for levodopa, and a new sustained-release formulation is in development.