Clinical medicine (London, England)
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Prescribed opioid misuse in North America is a public health crisis, with huge social, medical and economic repercussions. Surgery is an identified driver for persistent opioid use and misuse. The UK has also seen a surge in opioid consumption per capita and it is now necessary for primary and secondary care to work together to mitigate the problem of perioperative prescribed opioid misuse. This review discusses the identified drivers for persistent opioid use following surgery and discusses the remedial actions that must be taken by all stakeholders to mitigate the UK developing its own perioperative prescribed opioid crisis.
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In 2016, NHS England set up 10 integrated care systems (ICSs) which aim to devolve some responsibility for delivery of health and social care services to local healthcare providers in partnership with local government, social care, primary care networks, and voluntary and charitable organisations. These are new ways of working and provide an opportunity to better integrate perioperative care across the entire pathway from the moment of contemplation of surgery through to recovery at home. ⋯ We describe examples of initiatives in cancer pathways which are already proving successful and have caught the imagination of the local community at all levels, as well as examples of integrated perioperative care across the country which can be applied to other systems. We hope to demonstrate ways in which perioperative care can add value to a local health population given the right support and chance to deliver it.
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Review
Quality improvement and emergency laparotomy care: what have we learnt from recent major QI efforts?
More than 1.53 million adults undergo inpatient surgery in the UK NHS. Patients undergoing emergency abdominal surgery have a much greater risk of death than patients admitted for elective surgery. ⋯ Here we provide a critical review of what we currently know about the use of structured methods for improving the quality of healthcare services, with reference to the three initiatives. We find that using structured methods to improve care is the hallmark of quality improvement but attention must too be paid to the context in which these methods are used.
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Mortality from chronic kidney disease (CKD) is increasing. Most patients die from cardiovascular disease and management of cardiovascular risks is key to prevent both mortality and progression to end-stage renal disease. In 2014, the National Institute of Health and Care Excellence (NICE) introduced guidance to help general practitioners (GPs) manage CKD patients. ⋯ Post NICE guidelines, GPs are better in optimising BP. Diabetes management and lifestyle modifications need further improvement.
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Hypertensive encephalopathy (HE) is a subset of posterior reversible encephalopathy syndrome. It typically involves the posterior supratentorial structures, but variations do occur. However, isolated brainstem involvement in HE is rare, with a few cases reported in the literature. ⋯ Marked clinical-radiologic dissociation in this particular case was highly suggestive of hypertensive brainstem encephalopathy. Prompt recognition of the condition and aggressive treatment of hypertension in such patients is crucial to relieve oedema and to prevent life-threatening progression. Nevertheless, there is still a lack of awareness among physicians and radiologists regarding this rare clinical entity.