Clinical medicine (London, England)
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Prescribing for older adults represents a significant challenge as the UK population ages. Physiological decline and the rising prevalence of frailty increase the likelihood of altered pharmacodynamics and pharmacokinetics, suboptimal prescribing and adverse effects among this growing cohort of the population. ⋯ Does this agent reflect the priorities of the patient? Are there alternatives - with greater efficacy, effectiveness or tolerability - that might be considered? Are the dose, frequency and formulation appropriate? How does this prescription relate to concurrent medication? We also describe current drug therapies in two disease states with a predilection for older adults: Alzheimer's disease (AD) and osteoporosis. Using these examples we highlight the limitations of evidence-based medicine and guidelines in this cohort of the population, illustrating the reliance on sub-group analysis to demonstrate the efficacy of drug therapies for older adults in osteoporosis and the underutilisation of appropriate treatments for patients with AD as a result of flawed guidelines.
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Tick-borne infections are seen throughout the United States, with varying geographical locations. Many of these infections are also increasingly seen in Europe. Certain ticks (eg Ixodes) can transmit more than one infection. ⋯ In certain situations, empiric therapy may be required for tick-borne infections as severe illness with multiorgan failure can occur, particularly in older and immunocompromised hosts. This review describes the more commonly seen tick-borne infections: Lyme, babesiosis, anaplasmosis and Rocky Mountain Spotted Fever. More recently identified tick-borne infections, such as southern tick-associated rash illness and Borrelia miyamotoi, are also covered.
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Dengue is one of the most rapidly emerging viral infections globally, with 2.5 billion people now thought to live in dengue-endemic areas. In addition, reports of travel-related and autochthonous infections are increasing in non-endemic areas. ⋯ As dengue can present with non-specific symptoms of fever, headache and myalgias, the potential for misdiagnosis and inappropriate management by medical staff inexperienced with the disease is a concern. This short review will outline the latest World Health Organisation disease classification, potential complications, clinical assessment and management for clinicians working in non-endemic areas.
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Team assessment of behaviour (TAB) is the multi-source feedback assessment of professional behaviours that all UK foundation doctors must engage in twice during their two-year programme. TAB can identify the few underperforming trainees and provide feedback to consolidate the good practice of most. For optimum validity, TAB must be undertaken by a range of assessors, as specified in the national UK Foundation Programme curriculum. ⋯ Introduction of validity checking before sign-off greatly improved the numbers of valid assessments in 2011. This was partially sustained in 2012. Assurance of assessment validity is important to ensure delivery of appropriate constructive feedback and to allow early detection and remediation of signs of poor professional behaviours in foundation doctors.
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Case Reports
Lesson of the month 2: The limitations of steroid therapy in bradykinin-mediated angioedema attacks.
Acute angioedema attacks are conventionally treated with antihistamines and steroids, in line with a presumed mechanism of disease involving overwhelming mast-cell degranulation. This approach overlooks a small but important minority of cases in which attacks are bradykinin driven and exhibit poor responsiveness to steroid or anti-histamine therapy. ⋯ In the long-term, they require C1 esterase inhibitor sparing therapy and a treat-the-cause approach to reduce the risk of recurrent attacks. We present here a case of a middle-aged woman who presented with recurrent angioedema of initially uncertain aetiology.