Clinical Medicine最新文献

Larval debridement therapy (maggot therapy) uses sterile Lucilia spp. larvae to remove necrotic tissue, reduce bacterial burden and may support healing. The 2023 IWGDF wound-healing guideline could not recommend biosurgical debridement because it found no RCTs meeting its prespecified criteria. We searched PubMed, the Cochrane Library, Scopus and Google Scholar (inception-June 2025) for clinical studies of larval therapy in diabetes-related foot ulcers. Evidence is limited: one randomised trial (n=50) reported reductions in Staphylococcus aureus and Pseudomonas aeruginosa colonisation after 48-96h when larval therapy was added to standard care; another randomised trial (n=54) found faster debridement with free-range larvae than with bagged larvae. Observational studies suggest rapid debridement and possible reductions in bioburden, but healing outcomes are inconsistent and at high risk of bias. Larval therapy may be considered as an adjunct for sloughy/necrotic ulcers when conventional debridement is unsuitable, alongside multidisciplinary care. Larger trials are needed.

Background: . Peripheral lymphadenopathy (LA) has diverse causes and may indicate malignancy, particularly in referred patients.

Aim: . To characterize patients referred for unexplained-LA to a Quick Diagnosis Unit, and identify independent predictors of malignancy.

Design and methods: . We conducted a retrospective study of 485 consecutive adults evaluated for unexplained-LA between 2017 and 2023. The primary outcome was malignancy. Secondary outcomes included diagnostic delay and time to oncology referral. Demographic, clinical, and laboratory variables were compared across etiological groups. A parsimonious multivariable logistic regression model included five clinically relevant predictors identified in univariable analyses and supported by biological plausibility.

Results: . Median age was 46 years, and time to first visit was 11 days. Cervical nodes were most frequent (51.9%), followed by supraclavicular (18.6%). Malignancy was diagnosed in 20.8% of patients, with diagnostic delay of 26.5days (15.5-42). Other specific diagnoses were established in 35.5% of cases, while 43.7% were reactive. Malignant cases were older (60.8 vs 42 years), predominantly male (68.3% vs 44.5%), had higher drug exposure (50.0% vs 29.8%), and shorter symptom duration (45 vs 90 days). In multivariable analysis, independent predictors of malignancy were: age (OR 1.71 per 10-year increase), male sex (OR 3.25), lymph node size (OR 1.36 per 5-mm increase), indurated consistency (OR 3.42), and supraclavicular location (OR 4.96). Median time to oncology evaluation was 47 days.

Conclusion: . The QDU model enables timely diagnosis and detects malignancy in over 20% of cases. Recognizing clinical predictors may help prioritize high-risk patients and streamline diagnostic pathways.

Medication adherence refers to the extent to which a person's medication-taking behaviour corresponds with agreed recommendations from their clinician. Research shows that more than one-third of patients are non-adherent to their prescribed medications. Non-adherence is particularly significant in hypertension, as it complicates chronic disease management and may result in apparent treatment-resistant hypertension (aTRH), in which blood pressure remains uncontrolled despite appropriate pharmacological therapy and lifestyle measures. It is therefore important to assess adherence routinely, as non-adherence is one of the leading causes of aTRH. This article outlines a practical approach to recognising and assessing non-adherence using objective chemical adherence testing, and to managing medication non-adherence through non-judgemental, patient-centred discussion. Identifying non-adherence is vital, as failure to do so may lead to unnecessary treatment escalation, inappropriate investigations, and avoidable healthcare costs; while addressing it can support and improve patient-centred outcomes.

Incidence of falls related trauma in the older adult is exponentially increasing and requires a multidisciplinary approach at all stages of the encounter to optimise patient outcome. Orthogeriatric services bridge the gap between the older person, their acute presentation, and their chronic frailty and bone fragility. Despite improvements of fragility fracture pathways between surgical and medical teams, significant gaps of knowledge and communication remain. These gaps manifest as missed opportunities to address crucial medical issues, therapy needs, and bone health management in this vulnerable population. Here, we discuss themes to consider when approaching an older person at high falls risk or when presenting post fall. We emphasise the importance of delirium prevention, appreciation of frailty, and initiating bone fragility assessment and therapy in this vulnerable demographic.

Older people living with falls and frailty are common in emergency attendances, admissions and functional decline. Artificial intelligence (AI) and machine learning (ML) are increasingly incorporated in risk prediction, service streamlining and re-engineering, yet their roles in healthcare practice remain unclear. This CME article provides a practical overview for clinicians of acute care and internal medicine with a special interest in older people's care. We summarise emerging applications of AI and AI-assisted tools across the falls and frailty care pathway, from community support through the emergency department, orthogeriatrics and post-acute rehabilitation. We highlight potential benefits: enhanced risk stratification, facilitation of comprehensive geriatric assessment (CGA), rehabilitation and delivery of care transition programmes. We then discuss challenges and ethical concerns, for instance, 'digital ageism', automation bias and weak evidence for impact. Finally, we outline pragmatic questions and steps that clinicians can adopt when using AI-enabled tools in clinical settings.

Study objective: Artificial intelligence (AI) is being increasingly applied in medical education, yet its role in developing complex communication skills, such as breaking bad news, is less well defined. The Joint Royal Colleges of Physicians Training Board (JRCPTB) explored whether AI-generated guidance could complement or enhance traditional human-facilitated teaching methods in this sensitive domain.

Design: Two sets of guidance on breaking bad news were developed: one using a generative AI chatbot (ChatGPT) and the other through facilitated discussions among trainers and resident doctors.

Setting and participants: Each approach generated a series of summarised statements that were presented to members of the JRCPTB Specialty Advisory Committees (SACs) via an anonymous online consultation.

Main outcome measures: Respondents rated their agreement with each statement using a five-point Likert scale and provided qualitative feedback. Demographic data were collected to assess variations in preferences.

Results: A total of 80 assessments were completed for the traditional approach and 75 for the AI approach, involving 69 doctors across 19 specialties and 11 lay representatives. Both approaches produced a common core of 11 statements with high agreement (>85%) alongside unique statements specific to each method. Overall, 61% of respondents preferred the AI-generated content, 22% preferred the traditional approach and 17% expressed no preference. Female respondents showed a statistically significant preference for the AI approach (p = 0.003) although small study numbers restrict generalisability. No differences were found based on age, ethnicity or training background.

Conclusions: AI-generated content, when appropriately curated, can effectively support the teaching of sensitive communication skills, complementing traditional reflective learning methods. A hybrid model that integrates AI with human-facilitated discussions may offer a comprehensive and efficient approach to postgraduate medical education. Further research is warranted to ensure content quality, cultural and setting appropriateness, and to preserve trust in the supervisor-learner relationship.

Study objective: National clinical guidelines for the management of prolonged disorders of consciousness (PDOC) following sudden-onset brain injury were updated in 2020. Since then, clinical experience has grown. This paper reports on current practice.

Study design: A questionnaire was developed, tested and sent to rehabilitation and palliative medicine specialists, via the British Society of Physical and Rehabilitation Medicine and Association for Palliative Medicine. Anonymised responses were analysed.

Results: 63.5% (n = 61) of respondents were involved in the care of people with PDOC, with two-thirds working in palliative medicine. 44% of clinicians withdraw clinically assisted nutrition and hydration (CANH) in the patient's usual place of care. Where a decision to admit is taken, 43% will admit to a hospice inpatient unit. 87% of respondents do not arrange long line or central intravenous access prior to withdrawal of CANH. Ninety-five per cent of clinicians prescribe opioids and 92% prescribe sedatives for prn use or directly convert regular medications to a continuous subcutaneous infusion when withdrawing CANH. Most clinicians titrate according to need. In 81% of cases, there was no difficulty with symptom management on withdrawal of CANH. Forty-eight per cent of respondents worked with staff who expressed a conscientious objection to CANH, 40% in palliative medicine.

Conclusion: National guidance should be updated to reflect clinical practice with regard to place of care, the effectiveness of a subcutaneous route and the use of proportionate symptom management.