Clinical Medicine最新文献

{"title":"THE APPROACH TO A PREGNANCY AFTER BARIATRIC SURGERY.","authors":"Harriet D Morgan, Amy E Morrison, Malak Hamza, Cathy Campbell, Caroline Borg Cassar, Claire L Meek","doi":"10.1016/j.clinme.2024.100275","DOIUrl":"https://doi.org/10.1016/j.clinme.2024.100275","url":null,"abstract":"<p><p>With a rising worldwide incidence of obesity, particularly in the young, bariatric surgery offers an effective method of meaningful and sustained weight loss. At present, most bariatric procedures are carried out in women and increasingly in younger age groups. In line with the fertility benefits associated with weight loss, pregnancy after bariatric surgery is now a very common scenario. Although there is limited evidence to support optimal care in this group, most women appear to have good pregnancy outcomes, with reduced rates of preeclampsia and gestational diabetes (GDM). However, rates of stillbirth and small-for gestational-age (SGA) babies are increased, suggesting that screening and supplementation of micronutrients is likely to be very important in this cohort. The risks and benefits bariatric surgery may pose to pregnancy outcomes, both maternal and fetal, are largely dependent upon the degree of weight loss, weight stability upon entering pregnancy, surgical complications and the time interval between bariatric surgery and pregnancy. Ideally, preconception care would be more widely available, helping to assess and address micronutrient deficiencies and support preparation for pregnancy.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100275"},"PeriodicalIF":3.6,"publicationDate":"2024-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142863583","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Management of asthma in pregnancy.","authors":"C E Jones, Y Jamil","doi":"10.1016/j.clinme.2024.100277","DOIUrl":"https://doi.org/10.1016/j.clinme.2024.100277","url":null,"abstract":"<p><p>Asthma is the most common chronic disease to affect pregnant women and can have a significant effect on pregnancy outcomes with increased rates of preterm birth, premature delivery and caesarean section observed if poorly controlled. Pregnancy can also influence asthma control. Prescribing in pregnancy causes anxiety for patients and healthcare professionals and can result in alteration or undertreatment of asthma. Good asthma control with prompt and adequate management of exacerbations is key to reducing adverse pregnancy outcomes for both mother and fetus. The majority of asthma treatment can be continued as normal in pregnancy and there is emerging evidence of the safety of biologic medications also. This article aims to summarise the current evidence about asthma in pregnancy and guide the appropriate management of this population.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100277"},"PeriodicalIF":3.6,"publicationDate":"2024-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142863581","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical approach to palpitations in pregnancy.","authors":"Ferha Saeed, Kirun Gunganah, Anna S Herrey","doi":"10.1016/j.clinme.2024.100276","DOIUrl":"https://doi.org/10.1016/j.clinme.2024.100276","url":null,"abstract":"<p><p>Palpitations are common in pregnancy and warrant investigation. Palpitations may be caused by non-cardiac and cardiac causes. Patients with structural or functional abnormalities or inherited cardiovascular disease are more likely to develop arrhythmia, especially during pregnancy when the mother's body undergoes extensive physiological adaptations, which further contribute to an increased arrhythmia risk. While isolated ectopic beats do not require treatment, some heart rhythm disturbances can be life-threatening for mother and baby and mandate prompt intervention. Haemodynamically unstable patients should be electrically cardioverted. If the patient is stable, medical management is indicated, and early involvement of the pregnancy heart team can help facilitate appropriate treatment. In complex arrhythmia, consultation of an arrhythmia expert should be sought . Many antiarrhythmics are safe in pregnancy, and it is important to reassure the pregnant patient of this.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100276"},"PeriodicalIF":3.6,"publicationDate":"2024-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142853170","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Severe Acute Pulmonary Embolism in Pregnancy.","authors":"Dr Bhaskar Narayan","doi":"10.1016/j.clinme.2024.100274","DOIUrl":"https://doi.org/10.1016/j.clinme.2024.100274","url":null,"abstract":"<p><p>Pulmonary embolism is a significant cause of morbidity and mortality in pregnancy and the puerperium. In severe cases, it causes haemodynamic instability and can lead to cardiac arrest due to obstructive shock. Patients with acute PE can be risk-stratified, to guide their monitoring and treatment; this article focuses on intermediate and high-risk PE. The criteria for defining high-risk PE can be used unmodified in pregnancy. Diagnostic imaging should not be delayed due to pregnancy. LMWH and UFH can be used during pregnancy and breastfeeding and systemic thrombolysis can be used in obstetric patients, but there are significant bleeding risks and it should be reserved for high-risk PE with hypotension and shock. Although pregnancy and the puerperium are risk factors for PE, it is important to avoid early diagnostic closure, and to consider other causes for the patient's presentation.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100274"},"PeriodicalIF":3.6,"publicationDate":"2024-12-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142827614","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter to the Editor on Improving quality in adult long covid services. Implementing discrete event simulation, a quality improvement proposition.","authors":"Eman Albastaki","doi":"10.1016/j.clinme.2024.100280","DOIUrl":"https://doi.org/10.1016/j.clinme.2024.100280","url":null,"abstract":"","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100280"},"PeriodicalIF":3.6,"publicationDate":"2024-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142823813","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Role of the Neutrophil-to-Lymphocyte ratio in Predicting Outcomes Among Patients with Community-Acquired Pneumonia.","authors":"Yogesh Sharma, Campbell Thompson, Angelo Zinellu, Rashmi Shahi, Chris Horwood, Arduino A Mangoni","doi":"10.1016/j.clinme.2024.100278","DOIUrl":"https://doi.org/10.1016/j.clinme.2024.100278","url":null,"abstract":"<p><strong>Objectives: </strong>The value of the neutrophil-to-lymphocyte ratio (NLR) in predicting outcomes in patients hospitalised with community-acquired pneumonia (CAP) remains debated. This study evaluated whether NLR independently predicts clinical outcomes and enhances the predictive performance of the CURB-65 score in CAP patients.</p><p><strong>Methods: </strong>Data from CAP admissions at two Australian hospitals from 2018 to 2023 were analysed. NLR was calculated using admission neutrophil and lymphocyte counts. Patients were categorised into NLR >12 and NLR ≤12. Multilevel-multivariable regression models, adjusting for age, sex, Charlson index, CURB-65 score, Hospital-Frailty-Risk-Score (HFRS), and C-reactive protein (CRP), assessed outcomes including length-of-stay (LOS), Intensive Care Unit (ICU) admission, and in-hospital mortality.</p><p><strong>Results: </strong>Over six years, 7,862 CAP cases were hospitalised (mean age 75.1 years, 54.6% male). Mean NLR was 12.6, with 2,877 (36.6%) patients having an NLR >12. Those with NLR >12 were older males with higher disease severity and Charlson index (p<0.05). Adjusted analyses showed that NLR >12 was independently associated with prolonged LOS (IRR=1.11, 95% CI 1.08-1.13, p<0.001), increased risk of ICU admission (aOR=1.41, 95% CI 1.06-1.88, p=0.019), and higher in-hospital mortality (aOR=1.27, 95% CI 1.06-1.53, p=0.009). The predictive ability of the CURB-65 score for in-hospital mortality was good (AUC 0.68, 95% CI 0.66-0.70), while it was modest for the NLR (AUC 0.58, 95% CI 0.56-0.60). Incorporation of NLR to the CURB-65 score did not enhance its predictive ability (AUC 0.69, p>0.05).</p><p><strong>Conclusions: </strong>NLR independently predicts adverse outcomes in hospitalised CAP patients but does not improve the predictive performance of the CURB-65 score.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100278"},"PeriodicalIF":3.6,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142821866","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Acute confusion in pregnancy.","authors":"Amanda Hill, Francesca Neuberger","doi":"10.1016/j.clinme.2024.100273","DOIUrl":"10.1016/j.clinme.2024.100273","url":null,"abstract":"<p><p>If a woman is acutely confused in pregnancy, she will most likely present to an unscheduled care setting outside of maternity services. It is therefore essential that all clinicians working within general medicine are comfortable assessing pregnant women in this context. Useful resources are available to support assessing pregnant women who present acutely; however, confusion is beyond their scope. This article discusses important aspects to consider when assessing pregnant women and places emphasis on a systematic approach to ensure that obstetric and non-obstetric causes of confusion have been considered. Certain life-threatening diagnoses have been further discussed in more detail (Wernicke's encephalopathy, hyponatraemia, hypercalcaemia, acute fatty liver of pregnancy and thrombotic thrombocytopenia purpura). These conditions have been chosen as there is a significant risk of maternal mortality and morbidity as well as poor fetal outcomes if not recognised and treated early.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100273"},"PeriodicalIF":3.6,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142784336","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact on clinical outcomes, surgical interventions, anaesthetic decisions and complication rates following implementation of the NICE obstructive sleep apnoea guidelines during preoperative screening.","authors":"Gabrielle Shaw, Ricki Leggatt, Paige Roberts, Amanda Peace Witton, Nicole Moll, Akshay Dwarakanath","doi":"10.1016/j.clinme.2024.100266","DOIUrl":"10.1016/j.clinme.2024.100266","url":null,"abstract":"<p><strong>Introduction: </strong>Unidentified obstructive sleep apnoea (OSA) can lead to unexpected perioperative complications, unplanned postoperative admissions and increased length of hospital stay. NICE (National Institute for Health and Care Excellence) recommends a rapid preoperative assessment for patients undergoing elective surgery.</p><p><strong>Methods: </strong>We have evaluated the impact on implementing the NICE guidelines on clinical outcomes, surgical interventions, anaesthetic decisions and complication rates in surgical patients referred from the pre-assessment clinic prior to an elective intervention. All patients with a clinical suspicion of OSA based on a STOP-Bang score of 3 or more were referred for an overnight oximetry. Demographics, clinical outcomes and the impact on the planned surgical procedures were evaluated.</p><p><strong>Results: </strong>450 patients (Age 55 ± 14 years, male 69%, Epworth Sleepiness Scale (ESS) 7 ± 5) with a STOP-Bang score of 3 or more underwent overnight oximetry (32%; normal, 44%; mild, 15%; moderate and 9%; severe OSA). All patients with moderate and severe OSA were recommended for continuous positive airway pressure (CPAP) therapy to facilitate their surgical procedures and for long-term cardiometabolic benefits. Diagnosis of moderate/severe OSA had an impact on the surgical decision (P < 0.0001, odds ratio (OR) = 3.79, 95% confidence interval (CI) = 2.39-6.02). Severity of OSA affected the planned anaesthetic route (P < 0.0001, OR = 3.94, 95% CI = 2.21-7.05). No significant difference in day case vs non-day case, or need for unplanned admissions to critical care due to better planning pre-procedure. CPAP was initiated preoperatively in a third of patients (mean compliance 3.75 hours/day) and the overall complication rate was 11.6% in the moderate/severe OSA group vs 9.6% in the normal/mild OSA group.</p><p><strong>Conclusion: </strong>Prevalence of OSA is high in presurgical patients identified through preoperative screening. A diagnosis of moderate to severe OSA impacts surgical decision and planned anaesthetic route. Prior awareness of the diagnosis may help clinicians to identify the at-risk group. Timely CPAP initiation to facilitate surgery remains a challenge and, despite low compliance, CPAP may reduce postoperative complications. A multidisciplinary team (MDT) approach and a dedicated CPAP pathway post-diagnosis may help the clinicians and patients.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100266"},"PeriodicalIF":3.6,"publicationDate":"2024-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142681075","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Thromboelastography for rapid diagnosis of heparin-like anticoagulant release during anaphylaxis-induced coagulopathy in systemic mastocytosis: a case report.","authors":"Rajkumar Rajendram, Abdul Hadi Al-Qahtani, Farrukh Sheikh","doi":"10.1016/j.clinme.2024.100267","DOIUrl":"10.1016/j.clinme.2024.100267","url":null,"abstract":"<p><p>Anaphylaxis can induce life-threatening coagulopathy by releasing various mediators from activated mast cells. These mediators directly affect coagulation and fibrinolytic pathways, increasing the bleeding risk. Diagnosis and management of anaphylaxis-induced coagulopathy remain challenging. We report a unique case of a 44-year-old man with undiagnosed systemic mastocytosis who developed peanut-induced anaphylactic shock, resulting in cardiac arrest. Laboratory tests revealed elevated serum tryptase and severe coagulopathy. Thromboelastography, a point-of-care viscoelastic monitoring (VEM) test identified the presence of heparin-like anticoagulants within minutes. Bone marrow examination subsequently confirmed isolated mastocytosis. This case highlights the potential of VEM for rapid diagnosis and management of coagulopathy in patients with anaphylaxis, potentially aiding in the identification of mast cell degranulation in undifferentiated shock. We suggest that VEM should be considered in the investigation of patients with suspected anaphylaxis-induced coagulopathy.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100267"},"PeriodicalIF":3.6,"publicationDate":"2024-11-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142667057","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The feasibility of a novel national quality improvement programme for tobacco dependency treatment pathways in acute UK hospitals.","authors":"Robyn Fletcher, Alexander Hammant, Christina Moll, Miguel Souto, Sanjay Agrawal","doi":"10.1016/j.clinme.2024.100263","DOIUrl":"10.1016/j.clinme.2024.100263","url":null,"abstract":"<p><strong>Introduction: </strong>The prevalence of smoking remains stubbornly high in the UK despite comprehensive tobacco control measures. A national quality improvement (QI) approach to enhance the treatment of an estimated 1,000,000 annual hospital admissions of tobacco smokers could provide a new opportunity to improve population health and reduce healthcare demand. Barriers to QI include knowledge, costs and competing demands. This study aimed to evaluate the feasibility and effectiveness of a national QI programme hosted by the British Thoracic Society, focused on improving NHS tobacco dependency treatment in acute hospitals.</p><p><strong>Methods: </strong>The programme utilised the Model for Improvement as its QI framework and was delivered over a 6-month period. 25 teams from across the UK were upskilled through a series of webinars and coaching sessions and undertook QI projects focused on specific areas of their local tobacco dependency treatment pathways.</p><p><strong>Results: </strong>Results of the programme demonstrated improvements across the treatment pathway including screening for smoking status, rapid provision of nicotine replacement therapy to prevent nicotine withdrawal, referrals to inpatient tobacco dependency treatment teams and transfers of care to community services. Other programme outcomes included increases in QI knowledge, confidence and attitudes along with enhanced project management skills.</p><p><strong>Conclusion: </strong>This novel, national, online QI programme supported participating multidisciplinary teams in acute trusts across the UK to deliver tobacco dependency treatment pathway improvements using QI tools and methodology. This programme demonstrated the feasibility and effectiveness of delivering a national QI programme, at low cost using a microsystems approach applied to an important area of clinical medicine.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100263"},"PeriodicalIF":3.6,"publicationDate":"2024-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142615145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}