{"title":"Direct oral anticoagulants and the management of bleeding","authors":"Sara Boyce","doi":"10.1016/j.mpmed.2024.12.008","DOIUrl":"10.1016/j.mpmed.2024.12.008","url":null,"abstract":"<div><div>Venous and arterial thromboembolism are a major health burden worldwide and oral anticoagulation is fundamental in treating and preventing many thrombotic disorders. Direct oral anticoagulants (DOACs) have replaced traditional vitamin K antagonists for many indications for oral anticoagulation. Large Phase III studies and meta-analyses have shown that the risk of intracranial and fatal bleeding with DOACs is lower than with vitamin K antagonists. Despite this, when DOACs were first approved there was hesitancy among clinicians to prescribe them because of challenges in managing major bleeding, leading to the development and approval of two DOAC-specific reversal agents. Clear protocols ensuring the swift recognition and treatment of patients bleeding on DOACs, along with access to specific reversal agents and coagulation factors, improves patient outcomes.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 3","pages":"Pages 118-122"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143551845","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Stroke in the acute setting","authors":"Keith W Muir","doi":"10.1016/j.mpmed.2024.12.003","DOIUrl":"10.1016/j.mpmed.2024.12.003","url":null,"abstract":"<div><div>Acute stroke and transient ischaemic attack (TIA) are focal neurological syndromes of vascular origin and should be treated as medical emergencies. Brain imaging with computed tomography or magnetic resonance imaging is required to distinguish ischaemic stroke from intracerebral haemorrhage, recognize non-stroke pathologies that mimic stroke, and guide investigation into the underlying mechanism. Acute interventions of benefit in ischaemic stroke include intravenous thrombolysis with alteplase or tenecteplase and endovascular thrombectomy. Imaging additional to non-contrast computed tomography permits reperfusion treatment in a wider range of patients. Stroke unit care, aspirin and combination antiplatelet therapy benefit most patients. Decompressive hemicraniectomy reduces mortality in ischaemic stroke complicated by severe brain swelling. Intracerebral haemorrhage accounts for 10–15% of strokes, and outcome is improved by stroke unit care and active initial supportive management, which can include blood pressure lowering and anticoagulant reversal in some cases. TIA carries a high short-term risk of stroke, and immediate investigation and institution of secondary preventive treatment prevents a high proportion of this. Secondary prevention for ischaemic stroke and TIA should be tailored according to mechanism in individual patients.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 3","pages":"Pages 143-149"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143551850","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Clinical pharmacology and therapeutics: safe prescribing on the acute medical unit","authors":"Guhavarma Viswesvaraiah, Nikhil John","doi":"10.1016/j.mpmed.2024.12.010","DOIUrl":"10.1016/j.mpmed.2024.12.010","url":null,"abstract":"<div><div>Safe prescribing of medications on acute medical units (AMUs) is vitally important for ensuring high-quality and safe care for patients. Although the emphasis on safe prescribing has increased in recent years, prescribing-related errors still account for most clinical incidents on AMUs with a potential to harm patients. This article highlights the importance of safe prescribing, including the prescribing of essential drugs, adjustment of doses in acute kidney injury, use of drugs in pregnancy and lactation, identification of new drug interactions readers may not be familiar with and recent drug alerts on the use of certain antimicrobials.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 3","pages":"Pages 150-153"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143551851","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Acute management of alcohol and other drug use","authors":"Julia MA Sinclair, Julia FE Morris","doi":"10.1016/j.mpmed.2024.11.001","DOIUrl":"10.1016/j.mpmed.2024.11.001","url":null,"abstract":"<div><div>Intoxication and withdrawal syndromes are common presentations in acute medicine. Good management is based on a comprehensive history, including a collateral one, and thorough examination looking for patterns of signs and symptoms, backed up by appropriate investigations. A collaborative, empathic and non-judgemental approach that recognizes the patient's distress, explains the goals of management and sets clear boundaries significantly reduces potential complications and improves outcomes. An understanding of the pharmacology and clinical effects of alcohol, benzodiazepines, opioids and stimulants is essential to accurately diagnose and manage patients who may not be able to give an accurate history.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 2","pages":"Pages 57-63"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143150667","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Haematemesis and melaena – a review of upper gastrointestinal bleeding","authors":"Kit Morris, Thomas Hollingworth","doi":"10.1016/j.mpmed.2024.11.006","DOIUrl":"10.1016/j.mpmed.2024.11.006","url":null,"abstract":"<div><div>Upper gastrointestinal bleeding (UGIB) carries a 2–10% mortality rate. The most common aetiology is peptic ulcer disease (25%). Other causes include varices, malignancies and vascular malformations. Rapid recognition of UGIB and prompt resuscitation are essential. Pre-endoscopic scoring tools enable the identification of low-risk patients. Restrictive transfusion strategies carry mortality benefits. Endoscopic treatment can include adrenaline therapy, thermal cautery, mechanical clips, band ligation or application of haemostatic compounds. Post-endoscopic care is directed towards the underlying aetiology.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 2","pages":"Pages 82-87"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143150682","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"The acute abdomen","authors":"Ian Bailey, Cameron Biswas","doi":"10.1016/j.mpmed.2024.11.005","DOIUrl":"10.1016/j.mpmed.2024.11.005","url":null,"abstract":"<div><div>Acute physicians need to know how to start treatment and prioritize patients with an acute abdomen for investigation and treatment. However, delays in starting appropriate treatment and investigation remain common. This article gives an overview for non-surgical clinicians on how to assess and initiate management in these patients.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 2","pages":"Pages 88-91"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143150102","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Medical complications of surgery: an orthogeriatrician's perspective","authors":"Mark A Baxter","doi":"10.1016/j.mpmed.2024.11.008","DOIUrl":"10.1016/j.mpmed.2024.11.008","url":null,"abstract":"<div><div>Hip fracture is one of the most common admission diagnoses in the UK. Fractured neck of femur can be classified as a ‘frailty’ presentation because of an average age of >80 years, a clear association with ‘pathological falls’, including syncope, and a high number of co-morbidities. The combination of traumatic injury, frailty and surgery presents significant challenges to the managing team and requires a multidisciplinary approach to reduce the risk of perioperative complications, most commonly postoperative delirium, sepsis, cardiac complications, stroke and metabolic disturbance. Close monitoring with geriatric co-management has been shown to reduce complications and resultant morbidity, length of stay and mortality. Many lessons learnt from the experience of managing these very challenging patients has been transferred to other frail patients undergoing surgery in perioperative geriatric services and major trauma.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 2","pages":"Pages 64-66"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143150668","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Palliative care on the acute medical unit: an update","authors":"Anna John, Mark Banting, Andrew Jenks","doi":"10.1016/j.mpmed.2024.11.011","DOIUrl":"10.1016/j.mpmed.2024.11.011","url":null,"abstract":"<div><div>The acute medical unit is a busy environment, and nowhere else in the acute hospital can the contrast between providing life-saving treatment and care for a dying patient be so candidly seen. As Professor David Clark says, ‘A key part of the business of hospitals is death.’ It is vital that all healthcare professionals are competent and confident in recognizing patients who may be dying or have an uncertain recovery. Healthcare professionals must be able to assess the palliative care needs of these patients and their families, and communicate effectively and empathically. Care must be personalized, compassionate and well coordinated with the involvement of the multidisciplinary team and community team when needed. Tools such as the SPICT (Supportive and Palliative Care Indicators Tool) might also help identify patients with palliative care needs on an acute medical unit. Clinicians must be proactive in seeking opportunities to discuss the disease trajectory and explore patient and family wishes around future care.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 2","pages":"Pages 53-56"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143150664","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"The management of coma","authors":"Tim Cooksley, Mark Holland","doi":"10.1016/j.mpmed.2024.11.004","DOIUrl":"10.1016/j.mpmed.2024.11.004","url":null,"abstract":"<div><div>Coma is a medical emergency that can challenge the diagnostic and management skills of any clinician. A systematic and logical approach is necessary to make the correct diagnosis, the broad diagnostic categories being neurological, metabolic, diffuse physiological dysfunction and functional. Even when the diagnosis is not immediately clear, appropriate measures to resuscitate, stabilize and support a comatose patient must be rapidly performed. The key components in the assessment and management of a patient, namely history, examination, investigation and treatment, are performed in parallel, not sequentially. Unless the cause of coma is immediately obvious and reversible, help from senior and critical care colleagues is necessary. In particular, senior help is needed to make difficult management decisions in patients with a poor prognosis.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 2","pages":"Pages 96-101"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143150685","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"The shocked patient","authors":"Craig Prescott, Emma Rowland","doi":"10.1016/j.mpmed.2024.11.002","DOIUrl":"10.1016/j.mpmed.2024.11.002","url":null,"abstract":"<div><div>Prompt recognition of shocked patients and administration of therapy is essential. Haemodynamic stabilization and correction of the underlying cause should be based on the pathophysiological processes that are occurring. Monitoring the patient's response to treatment depends on careful observation in a high-dependency area along with serial lactate measurements. By optimizing the treatment of circulatory shock, its significant morbidity and mortality can be improved. Here, we give an overview of circulatory shock, recognition of shocked patients and principles of treatment, and explore some of the underlying causes of shock and their management.</div></div>","PeriodicalId":74157,"journal":{"name":"Medicine (Abingdon, England : UK ed.)","volume":"53 2","pages":"Pages 72-76"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143150686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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