Clinical medicine (London, England)
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After 60 years in which warfarin has been the only practical oral anticoagulant, a number of new oral anticoagulants are entering practice. These drugs differ in a several important respects from warfarin; most notably they have a reliable dose-response effect which means they can be given without the need for monitoring. ⋯ Large trials have established their non-inferiority to warfarin in a number of indications and in some cases their superiority. To date they have been licensed for prophylaxis following high risk orthopaedic procedures, non-valvular atrial fibrillation and treatment of venous thromboembolism, but is not clear that they will supplant warfarin in all areas.
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A working definition of personalised medicine is the delivery of a tailor-made treatment to the right patient at the right time. How close have recent advances in genetics come to realising this in the clinic?
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Eosinophilic oesophagitis is a clinico-pathologic diagnosis that describes patients with dysphagia (intermittent or continuous), food bolus obstruction or regurgitation, where endoscopy and biopsy reveals high concentrations of eosinophils in the lining of the oesophagus. At endoscopy, the presence of rings (trachealisation), furrows, micro-abscesses and strictures may be noted, but sometimes the appearance is normal. ⋯ It is important for all general physicians to recognise this and make an accurate diagnosis in order to give specific treatment. This may involve topical steroids, leukotreine D4 antagonists, dietary exclusions and dilatations.
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Acute myeloid leukaemia is a heterogeneous disease that occurs in all age groups but peaks in older age at around a median of 69-70 years where it has a frequency of 13-15/100,00/annum. With the changing demographics, the number of cases will increase in line with the older population. As the only treatment with curative intent is intensive chemotherapy, this presents an immediate therapeutic challenge for the majority of the disease.
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The number of older substance misusers requiring treatment is likely to double over the next couple of decades. However, there are many misconceptions and myths about this often hidden population. Older people misuse alcohol, nicotine, prescription medication and illicit drugs. ⋯ Patients present to a very wide variety of social and medical care settings, so screening and assessment for substance use are of paramount importance. This provides the opportunity to determine to what extent the substance problem is related to the presentation, which may be subtle and atypical in older people. Since evidence is accumulating of the benefit of treatment for substance problems in the older population, this group should not be marginalised and neglected by practitioners, researchers, educators and policy makers.