BRITISH MEDICAL JOURNAL VOLUME 289 29 SEPTEMBER 1984 799 few days later he noticed an area of numbness and paraesthesia below the right rib cage. These symptoms were more pronounced at night. A random blood glucose concentration was 12-3 mmol/l (221 mg/100 ml) and glycosylated haemoglobin 8°% (range in non-diabetics 5-7°%). Urea and electrolytes, serum Bl,, and results of liver function tests and urine analysis were normal. A Venereal Disease Research Laboratory test gave a negative result. Nerve conduction studies in the peroneal nerve were normal, though the sural nerve showed evidence of peripheral sensory neuropathy. Electromyography showed fibrillations and positive waves, an increase in the proportion of polyphasic motor unit potentials, and decreased interference patterns in the rectus abdominis innervated by T6-T12 on the right. Similar changes were seen in the right external oblique and thoracic paraspinal muscles. All studies on the left side gave normal results.Thoracic polyradiculopathy was diagnosed, and the sensory symptoms resolved over two months. No change was seen in the abdominal swelling. CommentThis patient presented with asymmetrical motor abnormalities in the abdominal muscles and mild and transient sensory symptoms affecting the right T6 and T7 dermatomes. He had electrophysiological evidence of only a mild sensory peripheral neuropathy, and, furthermore, there was no postural hypotension or clinical evidence of decreased sweating in the feet to suggest autonomic neuropathy. We could not perform standard heart rate dependent tests of autonomic function as the patient was in atrial fibrillation. Kikta et al reported on one patient with thoracic polyradiculopathy who was found to have abdominal swelling, though the patient was not diabetic and had an eight month history of abdominal pain. The diagnosis was confirmed by electromyography, and although a glucose tolerance test did not confirm diabetes it was suggestive of impaired glucose tolerance, which may have contributed to the aetiology of the polyradiculopathy.5Truncal polyradiculopathy should be considered in diabetic patients with unexplained abdominal pain or areas of muscle weakness. This case shows that such patients may present with no other neuropathic manifestations. If the diagnosis is considered early many unnecessary investigations might be avoided. Electromyography is the most helpful investigation in diagnosing this condition.3 5We thank Dr Jay Skyler for his encouragement. AJMB was supported in part by the Wellcome Foundation and Ayerst Laboratories. Accumulation of midazolam after repeated dosage in patients receiving mechanical ventilation in an intensive care unit Midazolam hydrochloride (Hypnovel) is a recently introduced imidazobenzodiazepine. Its potency and rapid onset and short duration of action after a single intravenous bolus make it an ideal agent for premedication or induction in anaesthesia for short surgical, endoscopic, and dental procedures. These same pharmacokinetic features would seem to make the dr...

SummaryOld people are commonly recervmg diuretics on admission to hospital. Diuretics are recognized as a risk factor for electrolyte disturbances; controversy exists about the relative risks of different combinations (in particular, co-amilozide [Moduretic] ). We recorded the drug history and serum electrolytes in 1000 consecutive admissions to a geriatric hospital, and examined the relative prescribing rates of various diuretics in the community.Full results were obtained in 929 patients. A history of diuretic prescription was present in 353 (38%) of the patients; the mean serum sodium in this group (95% CI 136.0-137.1 mmol/l) was lower than in the 586 not prescribed diuretics (137.1-137.9 mmol/l), The difference was small but statistically significant (95% CI difference =0.3-1.6 mmol/l; P

Delirium is a common presentation in older inpatients with COVID-19, and a risk factor for cognitive decline at discharge. The glaring gaps in the service provision in delirium care, regardless of aetiology, after a hospital admission pre-existed the pandemic, but the pandemic arguably offers an opportunity now to address them. Whilst a delirium episode in itself is not a long-term condition, the context of it may well be, and therefore patients might benefit from personalised care and support planning. There is no reason to believe that the delirium following COVID-19 is fundamentally different from any other delirium. We propose that the needs of older patients who have experienced delirium including from COVID-19 could be addressed through a new model of post-acute delirium care that combines early supported discharge, including discharge-to-assess, with community-based follow-up to assess for persistent delirium and early new long-term cognitive impairment. Such a drive could be structurally integrated with existing memory clinic services. To succeed, such an ambition has to be both flexible, adaptable and person-centred. To understand the impact on resource and service utilisation, techniques of quality improvement should be implemented, and appropriate metrics reflecting both process and outcome will be essential to underpin robust and sustainable business cases to support implementation of delirium care as a long-term solution.

ObjectiveTo determine research priorities in advanced heart failure (HF) for patients, carers and healthcare professionals.MethodsPriority setting partnership using the systematic James Lind Alliance method for ranking and setting research priorities. An initial open survey of patients, carers and healthcare professionals identified respondents’ questions, which were categorised to produce a list of summary research questions; questions already answered in existing literature were removed. In a second survey of patients, carers and healthcare professionals, respondents ranked the summary research questions in order of priority. The top 25 unanswered research priorities were then considered at a face-to-face workshop using nominal group technique to agree on a ‘top 10’.Results192 respondents submitted 489 responses each containing one or more research uncertainty. Out-of-scope questions (35) were removed, and collating the responses produced 80 summary questions. Questions already answered in the literature (15) were removed. In the second survey, 65 questions were ranked by 128 respondents. The top 10 priorities were developed at a consensus meeting of stakeholders and included a focus on quality of life, psychological support, the impact on carers, role of the charity sector and managing prognostic uncertainty. Ranked priorities by physicians and patients were remarkably divergent.ConclusionsEngaging stakeholders in setting research priorities led to a novel set of research questions that might not have otherwise been considered. These priorities can be used by researchers and funders to direct future research towards the areas which matter most to people living with advanced HF.

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