Clinical medicine (London, England)
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Computed tomography (CT) is readily available in developed countries. As one of the side effects includes an increased risk of cancer, interventions that may encourage more judicious use of CT are important. Behavioural economics theory includes the use of nudges that aim to help more informed decisions to be made, although these have been rarely used in hospitals to date. ⋯ There was a statistically significant reduction in the number of CT requested in the intervention hospital compared to the control hospital (-4.6%, 95% confidence intervals -7.4 to -1.7, p=0.002) in the 12 months after the intervention was implemented. We conclude that a simple, non-directional nudge intervention has the capacity to modify clinician use of CT. This approach is cheap, and has potential in helping support doctors make informed decisions.
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A 19-year-old patient presented with severe chest pain, which is not typical for cardiac angina. However, his smoking history and the strong family history of ischaemic heart disease coupled with evidence of progressive T-wave changes on his electrocardiogram (ECG) caused dilemma in deciding further management. His blood tests were normal apart from hypophosphataemia, and he had two negative troponin results. ⋯ He was given analgesia for a diagnosis of musculoskeletal chest pain and the next morning his ECG, arterial blood gases and phosphate levels all normalised. He had a normal echocardiogram and was reviewed by the cardiologist who diagnosed musculoskeletal chest pain which led to distress and hyperventilation causing hypophosphataemia and transient T-wave inversion. This case is a reminder of an under-recognised physiological phenomenon involving the cardiac conduction during hyperventilation.
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Nausea and vomiting in palliative care are commonly experienced symptoms, and the aetiology is often multifactorial. The most common causes are impaired gastric emptying, chemical causes (eg medication) and visceral causes (eg constipation). Close attention should be paid to the clinical features which may suggest the likely cause. Antiemetic therapy should be guided by the likely aetiology, although in practice, the clinical picture is often complex, and so regular reassessment is essential for adequate symptom control.
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The management of cancer-associated thrombosis (CAT) is largely informed by data from adequately powered randomised control trials. However, their exclusion criteria have invariably rendered the study populations unrepresentative of those seen day-to-day by palliative care practitioners. ⋯ We should, wherever possible, involve them in the decision-making process particularly where the evidence is lacking. By appreciating the values and concerns of our patients, we shall be able to plan care that most meets their needs.