Clinical Medicine最新文献

It is well known that older patients have a higher incidence of adverse hospital outcomes, such as inpatient falls, delirium and longer lengths of stay, and that older people are likely to become deconditioned during their time in hospital. It is often felt that deconditioning occurs as a consequence of a prolonged stay, however the adverse effects of immobility can occur within hours of arrival into urgent care. Hospital Associated Deconditioning is in fact a multi-systemic syndrome that manifests in a number of ways outside muscle weakness, including delirium, health care associated infection, new incontinence and falls, all of which can worsen outcomes for patients and lead to prolonged hospital stays. We outline strategies to embed preventing deconditioning into the care of older patients who present to the emergency and acute medical unit in order to avoid unnecessary harm and support patients to maintain their independence.

This case report describes a woman in her mid-40s of European ancestry presenting with recurrent profound hypotension, hypoproteinaemia, and haemoconcentration. She first presented following administration of a Japanese encephalitis vaccine. The initial differential diagnoses included sepsis or an anaphylactic reaction to the vaccine. No evidence of allergy or infection was found during extensive investigation including a lumbar puncture. Following a second similar presentation, she was diagnosed with Idiopathic Systemic Capillary Leak Syndrome (ISCLS). Her presentation was highly atypical due to the high frequency of episodes encountered (34 over a near six-year period). A variety of triggers for episodes were identified including Covid-19 infections, influenza infection and vaccinations. We discuss her clinical presentation, investigations, ISCLS episode triggers and management. This highlights the benefits of Intravenous Immunoglobulins (IVIg), both for prophylaxis and the acute treatment of ISCLS episodes.

We present a 29-year-old immunocompetent Uzbek woman with an ulcerated nodular lesion on her arm following an insect bite, caused by Leishmania major and confirmed by polymerase chain reaction (RT-PCR). The patient was initially treated with oral itraconazole and topical imiquimod. However, the disease progressed over three-months and systemic liposomal amphotericin B was subsequently initiated. Magnetic resonance imaging (MRI) revealed deep tissue involvement, marking the first such finding in sporotrichoid cutaneous leishmaniasis caused by L. major. This case emphasizes the diagnostic and treatment challenges of atypical cutaneous leishmaniasis and highlights the value of imaging techniques in assessing disease extent.

Background: Metabolic syndrome is a constellation of cardiovascular risk factors and has been associated with a higher risk of mortality. Albuminuria was previously part of the criteria for metabolic syndrome. We investigated the associations of albuminuria and metabolic syndrome with all-cause mortality among patients with coronary artery disease.

Methods: We enrolled patients who had coronary angiography-proved coronary artery disease but no history of diabetes between 2009 and 2013. All patients underwent an oral glucose tolerance test to determine their glucose regulation state. Metabolic syndrome was determined using the criteria of National Cholesterol Education Program Adult Treatment Panel III. A spot urine sample was collected to determine the urinary albumin to creatinine ratio (UACR). Information on all-cause mortality was confirmed until March 2023. Cox-proportional hazard models were conducted to examine the associations of metabolic syndrome and albuminuria with all-cause mortality.

Results: A total of 823 patients with coronary artery disease were analysed. After a median follow-up period of 8.94 years, patients with metabolic syndrome had no significant difference in all-cause mortality compared with those without metabolic syndrome (adjusted hazard ratio [HR] 0.826, 95% CI 0.568-1.201, p = 0.317). In contrast, patients with albuminuria (UACR ≥ 30 mg/g) had an independently higher risk of all-cause mortality (adjusted HR 1.529, 95% CI 1.057-2.212, p = 0.024) compared with those who had normoalbuminuria.

Conclusions: Albuminuria was independently associated with all-cause mortality in patients with coronary artery disease but no history of diabetes, while the presence of metabolic syndrome was not.

Introduction: Adverse events (AEs) involve a safety problem and compromise the quality of care, but evidence on how they affect the prognosis of patients is limited.

Objective: In this study, the relationship between the presence of AEs and in-hospital mortality among patients is analysed, and their characteristics are compared.

Material and methods: An observational study with a cross-sectional design was conducted in 32 hospitals of varying complexity in the Community of Madrid. The clinical history of 9,111 patients was analysed. Patients who were in the emergency room and those admitted to psychiatric units or centres were excluded. All hospitalisations were reviewed using the Harvard Medical Practice Study methodology for the detection and characterisation of AEs. The association between in-hospital mortality and the number of AEs was analysed with two multivariate models via logistic regression: 1) an explanatory model adjusted for confounders and 2) a predictive model of in-hospital mortality. A descriptive analysis of the differential characteristics of the AE was performed for the patients who died.

Results: In-hospital mortality was 5%, with a higher incidence of AEs in patients who died (29.8% versus 11.9%; p < 0.005). The presence of 1 AE (OR [95% CI]: 2.1 [1.6 to 2.7]) or ≥3 AEs (2.4 [1.1 to 5.1]) significantly increased the odds of mortality. In addition, the increase in the number of AEs was a predictor of mortality without a dose-response effect. The AEs that were most associated with in-hospital mortality were those related to care (15.5%; p = 0.047), and 15.3% of the AEs that occurred during ward care contributed to in-hospital mortality.

Conclusion: There is an association between AEs and in-hospital mortality. The presence of at least 1 AE implies a critical event in the patient's prognosis without a dose-response effect. Reducing AEs related to care in patients with comorbidities is positioned as an efficient strategy for improving health outcomes.

Diabetes is a growing public health concern. Approximately 20% of acute NHS hospital beds are occupied by individuals with diabetes. Following the recent NICE (National Institute for Health and Care Excellence) updates, diabetes technologies are increasingly available in the NHS. Despite the benefits, they present challenges, eg unfamiliarity, insufficient education, and lack of confidence of general physicians who are increasingly likely to encounter people using these technologies, presenting with acute illnesses. This review aims to update the general physicians with diabetes technologies such as continuous glucose monitors, insulin pumps, hybrid closed loop systems and how to troubleshoot in acute illnesses, diabetes emergencies, perioperative management and radiological investigations. While it is important to develop consistent inpatient care pathways and out-of-hours support from diabetes teams, it is vital to enhance the knowledge and confidence of non-diabetes physicians. Further research is warranted to support the use of technology in inpatient settings and diabetes emergencies.

Two types of antibody could confuse the differential diagnosis of hypoglycaemia. One is insulin-binding autoantibodies (IAA), a double hit causing hypoglycaemia of insulin autoimmune syndrome (IAS, also known as Hirata's disease) as well as distorting measurements of insulin and/or C-peptide. The clinical manifestations and initial endocrine results in patients with IAS would mimic and masquerade as other common pathologies, as well as factitious hypoglycaemia in adults, children and newborns. The second type is non-IAA autoantibodies which, if fortuitously/incidentally present in patients with hypoglycaemia, could interfere with insulin and/or C-peptide immunoassay measurements, also confusing differential diagnosis. Currently, testing for antibodies (all classes/subclasses) by simple method such as polyethylene glycol (PEG) is not usually included among first-line investigations of hypoglycaemia, causing delayed diagnosis or diagnostic misapplication. Detection of antibodies, irrespective of their nature, warrants cautious and careful differential diagnosis, averting hospitalisation and curtailing unnecessary and expensive investigations.

Background: Chronic obstructive pulmonary disease (COPD) contributes significantly to global morbidity and mortality and high economic burdens to healthcare systems. Emerging evidence suggests that sodium/glucose co-transporter-2 inhibitors (SGLT2i), beyond their use in type 2 diabetes mellitus (T2DM) and heart failure (HF), offer multifaceted immunomodulatory and anti-inflammatory effects which may offer positive outcomes in patients with COPD.

Objective: Investigate the impact of SGLT2i on inpatient outcomes - specifically, hospital length of stay (LOS), admission frequency, and use of acute non-invasive ventilation (NIV).

Methods: We conducted a 24-month retrospective observational study of adults with spirometry-confirmed COPD admitted to University Hospitals Coventry and Warwickshire between April 2022 and April 2024. Patients receiving SGLT2i for ≥30 days prior to study start formed the treatment group. Multivariable Poisson logistic regression was used to analyse the association between SGLT2i use and key outcomes, adjusting for demographics, disease severity, comorbidities and concurrent therapies.

Results: About 1,197 admissions of 627 patients met the inclusion criteria, with 32 patients (5%) prescribed SGLT2i. SGLT2i use was associated with a statistically significant 26% reduction in hospital LOS (95% CI 0.62-0.87; p ≤ 0.001), independent of co-existing HF or T2DM. However, there was no significant reduction in admission frequency (IRR 0.84, 95% CI: 0.62-1.09, p = 0.212) or acute NIV use (OR 2.62, 95% CI: 0.35-13.26, p = 0.277) among SGLT2i users.

Conclusions: SGLT2i therapy in COPD patients was associated with a significantly reduced hospital length of stay during exacerbations, regardless of underlying heart failure or diabetes status. However, no differences were observed in admission frequency or acute NIV utilisation. These findings support the hypothesis of a beneficial anti-inflammatory or cardiopulmonary effect of SGLT2i in COPD and warrant further investigation through prospective trials to explore their therapeutic role in this population.