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    Response.
    Clin Med (Lond) 2017 10;17(5):478-479
    Kings College London; Consultant stroke physician, Guy's and St Thomas' NHS Foundation Trust; National clinical director for stroke, NHS England; London stroke clinical director, London, UK.

    Lesson of the month 2: Autoimmune sequelae of anti-GAD antibodies - thinking outside the box.
    Clin Med (Lond) 2017 Oct;17(5):473-474
    University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK.
    A 52 year-old female with no significant medical problems presented with left-sided weakness, unsteady gait and speech disturbance. It was thought that she had neuro-inflammation and she remained clinically stable. Several years later, she was diagnosed with latent autoimmune diabetes of adulthood. Read More

    Lesson of the month 1: Spontaneous septic thrombophlebitis presenting with bacteraemia diagnosed by PET-CT scan.
    Clin Med (Lond) 2017 Oct;17(5):471-472
    Southend University Hospital NHS Foundation Trust, Southend, UK.
    Spontaneous septic thrombophlebitis is a rare complication of Staphylococcus aureus bacteraemia. Its true incidence is unknown as septic thrombus is not often considered as a source in the typical 'screen' of tests used to find the source of a bacteraemia.Positron emission tomography computerised tomography (PET-CT) is becoming increasingly available to physicians, is highly sensitive and yields specific anatomical information regarding abnormal metabolically active sites in infection, inflammation and neoplasia. Read More

    Molecular radiotheranostics for neuroendocrine tumours.
    Clin Med (Lond) 2017 Oct;17(5):462-468
    University College London Hospitals NHS Foundation Trust, London, UK.
    This article discusses the important role of nuclear medicine imaging and therapy in the management of neuroendocrine tumours (NETs). Somatostatin receptor scintigraphy has a high impact on patient management versus conventional imaging. Molecular radiotherapy is an important part of the management of patients with NETs. Read More

    Molecular radiotheragnostics in prostate cancer.
    Clin Med (Lond) 2017 Oct;17(5):458-461
    Brighton and Sussex University Hospitals NHS Trust and honorary reader and BSMS PET-CT lead, Brighton and Sussex Medical School, Brighton, UK.
    Two different molecular radio-theragnostic principles are applied in prostate cancer, providing a personalised management for those patients. Firstly, radiopharmaceuticals with the same or similar mechanism of action but different energy (gamma-γ, eg (99m)Tc-diphosphonates or positron-β+, eg 18F-NaF emitting isotopes) can be used to identify patients with osteoblastic metastases for a treatment with bone seeking beta (β-) or alpha (α-) emitting radionuclides to deliver targeted molecular radiotherapy. A number of such β- emitting molecules have been used for bone palliation. Read More

    Molecular radiotheragnostics in thyroid disease.
    Clin Med (Lond) 2017 Oct;17(5):453-457
    Kings College London, London, UK.
    Molecular radiotheragnostics directly links nuclear medicine diagnostic imaging to therapy. The imaging study is used to detect a specific molecular target associated with a disease process. A radiotherapeutic molecule with a similar biodistribution to the diagnostic agent can then be used to deliver targeted therapy. Read More

    Selective internal radiation therapy for liver tumours.
    Clin Med (Lond) 2017 Oct;17(5):449-453
    Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
    Primary and secondary liver malignancies are common and associated with a poor prognosis. Surgical resection is the treatment of choice; however, many patients have unresectable disease. In these cases, several liver directed therapies are available, including selective internal radiation therapy (SIRT). Read More

    New horizons in multimodality molecular imaging and novel radiotracers.
    Clin Med (Lond) 2017 Oct;17(5):444-448
    Department of Cancer Imaging and Guy's & St Thomas' PET Centre, King's College London, London, UK
    Positron emission tomography (PET)/computerised tomography is now established in clinical practice for oncologic and non-oncological applications. Improvement and development of scanner hardware has allowed faster acquisitions and wider application. PET/magnetic resonance imaging offers potential improvements in diagnostic accuracy and patient acceptability but clinical applications are still being developed. Read More

    Acute respiratory distress syndrome .
    Clin Med (Lond) 2017 Oct;17(5):439-443
    William Harvey Research Institute, Queen Mary University of London, London, UK
    Acute respiratory distress syndrome is a common cause of acute respiratory failure that is underdiagnosed both inside and outside of intensive care units. Progression to the most severe forms of the syndrome confers a mortality rate greater than 40% and is associated with often severe functional disability and psychological sequelae in survivors. While there are no disease-modifying pharmacotherapies for the syndrome, this progression may be prevented through the institution of quality improvement measures that minimise iatrogenic injury associated with acute severe illness. Read More

    An unusual case of refractory status epilepticus in a young lady: anti-NMDA receptor encephalitis.
    Clin Med (Lond) 2017 Oct;17(5):436-438
    Islamic Science University of Malaysia, Pandan Indah, Kuala Lumpur, Malaysia.
    We describe a case of a young lady with anti-NMDA (N-methyl-D-aspartate) receptor encephalitis, who initially presented with status epilepticus. Her seizures and orofacial dyskinesia were refractory to four anticonvulsants. She received intravenous immunoglobulin and a left ovarian tumour (an associated feature) was resected. Read More

    Endocrine abnormalities in lithium toxicity.
    Clin Med (Lond) 2017 Oct;17(5):434-436
    Royal Liverpool and Broadgreen University Hospital NHS Trust, Liverpool, UK.
    Lithium toxicity can manifest as a variety of biochemical -abnormalities. This case report describes a patient -presenting to the emergency department with neuropsychiatric -symptoms on a background of bipolar disorder, for which she was prescribed lithium for 26 years previously. Cases of lithium toxicity are rare but can be severe and this case report -demonstrates to clinicians that they must be thorough in investigating patients with lithium toxicity, as there are many potential abnormalities that can manifest concurrently. Read More

    Ulcerative colitis: management in adults, children and young people - concise guidance .
    Clin Med (Lond) 2017 Oct;17(5):429-433
    Sheffield Teaching Hospitals NHS Trust and honorary professor of gastroenterology, University of Sheffield, Sheffield, UK
    Ulcerative colitis is a chronic, relapsing and remitting -inflammatory disease of the colon and rectum. Effective -management requires prompt recognition and treatment of those with acute relapses as well as appropriate choice and monitoring of drugs for maintenance of remission. This therefore involves specialist gastroenterology teams as well as acute and general physicians and primary care clinicians. Read More

    Sleep in adolescents and young adults.
    Clin Med (Lond) 2017 Oct;17(5):424-428
    Central Manchester University Hospitals NHS Foundation Trust, Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester and NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
    Sleep has an important role in maintaining health and wellbeing; this relationship is becoming increasingly recognised for adolescents and young adults. Many physicians will encounter young people who present with complaints or conditions that have some relation to poor sleep. This review article looks at why sleep matters within this population group, how it can impact on longer term health consequences and discusses some tools to help enable the clinician to evaluate and address sleep within clinical practice. Read More

    Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal .
    Clin Med (Lond) 2017 Oct;17(5):419-423
    Maroondah Hospital, Melbourne, Australia.
    Current guidelines support the well-established clinical practice that patients who present with atrial fibrillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation. However, with increasing evidence that short runs of AF confer significant risk of stroke, on what evidence is this 48-hour rule based and is it time to adopt a new approach? We review existing evidence and suggest a novel approach to risk stratification in this setting. Overall, the risk of thromboembolism associated with acute cardioversion of patients with AF that is estimated to be of <48 hours duration is low. Read More

    The efficacy of a low-fat diet to manage the symptoms of bile acid malabsorption - outcomes in patients previously treated for cancer.
    Clin Med (Lond) 2017 Oct;17(5):412-418
    GI unit, United Licolnshire Hospitals NHS Trust, Lincoln County Hospital, Lincoln, UK.
    Dietary fat ingestion triggers bile secretion into the gastrointestinal tract. Bile acid malabsorption affects >1% of the population, causing loose stool and other gastrointestinal symptoms. The diagnosis is frequently missed. Read More

    Thoracic ultrasound experiences among respiratory specialty trainees in the UK.
    Clin Med (Lond) 2017 Oct;17(5):408-411
    St Thomas' Hospital, London, UK.
    Achieving competence in thoracic ultrasound is a mandatory requirement for the successful completion of respiratory specialty training in the UK. We evaluated trainee competencies, access to training and confidence in thoracic ultrasound by means of a nationally distributed survey with the participation of 202 (of approximately 600) respiratory trainees. 65. Read More

    Statin therapy in patients with community-acquired pneumonia.
    Clin Med (Lond) 2017 Oct;17(5):403-407
    Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.
    Community-acquired pneumonia (CAP) is the leading cause of death from infection in developed countries. There is evidence of an association between improved survival from infection and statin use. The possible beneficial effects of statins are complicated by the common use of macrolide antibiotics for pneumonia, with current guidance suggesting that concurrent macrolide and statin use is contraindicated. Read More

    A 4-week wait 'fast-track' sleep service is effective at establishing vocational drivers on continuous positive airway pressure.
    Clin Med (Lond) 2017 Oct;17(5):401-402
    The Lister Hospital Sleep Service, East & North Hertfordshire NHS Trust, Stevenage, UK.
    We sought to establish whether an expedited or 'fast-track' NHS service to diagnose obstructive sleep apnoea (OSA) and establish vocational drivers on continuous positive airway pressure (CPAP) within 4 weeks of referral was possible. This model is recommended by the OSA Partnership Group. In total, 55 vocational drivers were referred to two sleep services. Read More

    Routine screening in the general hospital: what happens after discharge to those identified as at risk of dementia?
    Clin Med (Lond) 2017 Oct;17(5):395-400
    Oxford University Hospitals NHS Trust and University of Oxford, Oxford, UK
    Cognitive screening is recommended for older patients with unplanned hospital admission. We determined rates of reassessment/specialist memory referral after routine inclusion of at risk of dementia status in discharge documentation to primary care. Questionnaires were sent to relevant GP practices on consecutive patients aged ≥75 years identified as at risk and discharged 6 months earlier. Read More

    Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis .
    Clin Med (Lond) 2017 Oct;17(5):389-394
    University Hospitals Birmingham NHS Foundation Trust and Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
    Efficient management of diabetic ketoacidosis (DKA) improves outcomes and reduces length of stay. While clinical audit improves the management of DKA, significant and sustained improvement is often difficult to achieve. We aimed to improve the management of DKA in our trust through the implementation of quality improvement methodology. Read More

    Lesson of the month 2: Dry skin, yellow nails and breathlessness.
    Clin Med (Lond) 2017 Jul;17(4):371-372
    Southmead Hospital, Bristol, UK.
    Interstitial lung disease (ILD) is a common clinical problem, representing a group of diseases consisting of inflammation and progressive fibrosis of the lung. In some cases, an underlying cause is not identified; however, a significant proportion of ILD is associated with connective tissue disease (CTD). A detailed history and examination is the most important part of the assessment of patients with suspected ILD and will direct further investigation. Read More

    Lesson of the month 1: Large vessel vasculitis - a diagnostic challenge and the role of 18-fluorodeoxyglucose positron emission tomography.
    Clin Med (Lond) 2017 Jul;17(4):369-370
    Gloucestershire Royal Hospitals NHS Foundation Trust, Gloucester, UK.
    Large vessel vasculitis can pose a significant diagnostic challenge. It may be insidious in onset with the only presenting symptoms consisting of constitutional compromise. It may mimic other pathologies and the only serological abnormalities may be abnormal inflammatory markers. Read More

    The emergence of sarcopenia as an important entity in older people.
    Clin Med (Lond) 2017 Jul;17(4):363-366
    University of Dundee, Dundee, UK
    Sarcopenia refers to the loss of muscle mass and strength seen with advancing age. The pathophysiology is multifactorial, with loss of muscle satellite cells, changes in hormonal systems, chronic inflammation, oxidative stress and anabolic resistance to protein utilisation all implicated. Older age, female sex and immobility are important risk factors. Read More

    Prevention of falls in hospital.
    Clin Med (Lond) 2017 Jul;17(4):360-362
    Kent Community Health NHS Trust, Ashford, UK.
    Falls among inpatients are the most frequently reported safety incident in NHS hospitals. 30-50% of falls result in some physical injury and fractures occur in 1-3%. No fall is harmless, with psychological sequelae leading to lost confidence, delays in functional recovery and prolonged hospitalisation. Read More

    The physician's role in perioperative management of older patients undergoing surgery.
    Clin Med (Lond) 2017 Jul;17(4):357-359
    Guy's and St Thomas' NHS Foundation Trust, London, UK and King's College, London, UK.
    Life-sustaining and life-improving surgical interventions are increasingly available to older, frailer patients, many of whom have multimorbidity. Physicians can help support perioperative multidisciplinary teams with assessment and preoperative optimisation of physiological reserve, comorbidities and associated geriatric syndromes. Similar structured support can be useful in the postoperative period where older patients are at increased risk of delirium, medical complications, increased functional dependency and where discharge planning can prove more difficult than in younger cohorts. Read More

    Making difficult decisions with older patients on medical wards.
    Clin Med (Lond) 2017 Jul;17(4):353-356
    Nottingham University Hospitals NHS Trust, Nottingham, UK
    Decision making with older people can be difficult because of medical complexity, uncertainty (about prognosis, treatment effectiveness and priorities), difficulties brought by cognitive and communication impairment and the multiple family and other stakeholders who may need to be involved. The usual approach, based on balancing benefits and burdens of a treatment, and then deciding on the basis of autonomy (or best interests for someone lacking mental capacity), within the constraints of resources and equity, remains valid, but is often inadequate. In addition, approaches relying on optimal communication and relationship building and professional virtues are important. Read More

    Acute geriatrics at the front door.
    Clin Med (Lond) 2017 Jul;17(4):350-353
    Newcastle University, Newcastle upon Tyne, UK.
    Older people with frailty and urgent care needs are major uses of health and social care services. Comprehensive geriatric assessment (CGA) is an evidence-based approach to improving their outcomes, as well as improving service outcomes. Geriatricians form a small proportion of the overall workforce and cannot address the population need alone, so all clinicians (doctors, nurses, therapists and so on) need to engage in delivering CGA as a process of care, underpinned by specific competencies - which can be developed. Read More

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