Clinical Medicine最新文献

Objective: Determining the accuracy of a method calculating the Gold Standards Framework Surprise Question (GSFSQ) equivalent end-of-life prognosis amongst hospital inpatients.

Design: A prospective cohort study with regression calculated 1-year mortality probability. Probability cut points triaged unknown prognosis into the GSFSQ equivalent "Yes" or "No" survival categories (> or < 1-year respectively), with subsidiary classification of "No". Prediction was tested against prospective mortality.

Setting: An acute NHS hospital.

Participants: 18,838 acute medical admissions.

Interventions: Allocation of mortality probability by binary logistic regression model (X²=6650.2, p<0.001, r² = 0.43) and stepwise algorithmic risk-stratification.

Main outcome measure: Prospective mortality at 1-year.

Results: End-of-life prognosis was unknown in 67.9%. The algorithm's prognosis allocation (100% vs baseline 32.1%) yielded cohorts of GSFSQ-Yes 15,264 (81%), GSFSQ-No Green 1,771 (9.4%) and GSFSQ-No Amber or Red 1,803 (9.6%). There were 5,043 (26.8%) deaths at 1-year. In Cox's survival, model allocated cohorts were discrete for mortality (GSFSQ-Yes 16.4% v GSFSQ-No 71.0% (p<0.001). For the GSFSQ-No classification, the mortality Odds Ratio was 12.4 (11.4 - 13.5) (p<0.001) vs GSFSQ-Yes (c-statistic 0.72 (0.70 - 0.73), p<0.001; accuracy, positive and negative predictive values 81.2%, 83.6%, 83.6%, respectively). Had the tool been utilised at the time of admission, the potential to reduce possibly avoidable subsequent hospital admissions, death-in-hospital, and bed days was significant (p<0.001).

Conclusion: This study has unique in methodology with prospectively evidenced outcomes. The model algorithm allocated GSFSQ equivalent EOL prognosis universally to a cohort of acutely admitted patients with statistical accuracy validated against prospective mortality outcomes.

Adrenal haemorrhage in pregnancy is rare but can lead to significant maternal and fetal morbidity if unrecognised. We present the case of a 25-year-old woman in her second pregnancy, who was admitted at 34 + 4 weeks of gestation with severe abdominal pain. Despite initial unremarkable assessments, further imaging revealed a left adrenal haemorrhage, with evidence of prior right adrenal infarction, resulting in primary adrenal insufficiency. Haematological investigations later confirmed heterozygous factor V Leiden as a likely contributing factor. This report underscores the diagnostic challenges of adrenal pathology in pregnancy, where symptoms may overlap with more common conditions. Immediate management with hydrocortisone therapy, supported by a multidisciplinary team (MDT), was employed, with a successful outcome for both mother and child following delivery by caesarean section.

Aim: To evaluate an intervention (a film and electronic leaflet) disseminated via text message by general practices to promote COVID-19 preventative behaviours in Black and South Asian communities.

Methods: We carried out a before-and-after questionnaire study of attitudes to and implementation of COVID-19 preventative behaviours and qualitative interviews about the intervention with people registered with 26 general practices in England who identified as Black or South Asian.

Results: In the 108 people who completed both questionnaires, we found no significant change in attitudes to and implementation of COVID-19 preventative behaviours, although power was too low to detect significant effects. A key qualitative finding was that participants felt they did not 'belong' to the group targeted by the intervention.

Conclusion: Interventions targeting ethnic minorities in the UK need to acknowledge the heterogeneity of experience and circumstances of the target group so that people feel that the intervention is relevant to them.

Point of care ultrasound (POCUS) has revolutionised modern day medicine and has widespread utilisation throughout healthcare settings. Despite the availability of ultrasounds, there are no requirements for internal medicine trainees (IMTs) to undergo any form of POCUS training. This study aimed to explore the perceptions and experience of IMTs of POCUS. A multicentre survey was distributed via mass email to all internal medicine trainees (IMT1-ST8) across two deaneries in Southwest England. A total of 42% (213/509) IMTs completed the survey. Of these 97% (207/213) contributed to the acute medical or general medical rota and 95% (202/213) of trainees reported performing invasive procedures on call. Training in ultrasound site selection was reported by 30% (63/213) of IMTs and 11% (23/213) worked in a trust with accessible POCUS training. Formal POCUS accreditation was reported by 16.0% (34/213) of trainees. Identifying sonographic findings of common medical conditions was considered useful by 86.9% of trainees. Identifying pleural effusions being the most useful (99%, 211/213), whilst identifying a deep vein thrombosis was the least (87%,185/213). Higher confidence scores were reported for ultrasound assisted as opposed to ultrasound guided ascitic or pleural procedures, although this was not significant. On a 10-point Likert scale most trainees highly rated POCUS training (Median = 10, interquartile range 8-10). Free text responses supported POCUS training in the IMT curriculum. We found IMTs perceive POCUS training as highly valuable. However, few IMT trainees are obtaining sufficient experience or training of POCUS. Opportunities for enhanced POCUS training should be embedded in training programmes.

Atopic eczema (eczema; also known as atopic dermatitis) is a chronic inflammatory skin condition. The burden of eczema can be very substantial with significant itch, skin pain, secondary infection, sleep disturbance and psychological distress. Eczema is common in pregnancy. It is therefore important to offer effective treatment to pregnant women, especially those with moderate to severe disease where the burden is greatest. When eczema cannot be adequately managed with skin-directed approaches such as topical preparations and/or phototherapy, systemic therapy may be required to achieve disease control and requires early input from dermatology specialists. The aim of this short review is to summarise this approach.

Introduction: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

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 anti-arrhythmics are safe in pregnancy, and it is important to reassure the pregnant patient of this.

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 pre-eclampsia 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 that 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.