Clinical Medicine最新文献

Introduction: Unidentified OSA can lead to unexpected perioperative complications, unplanned postoperative admissions and increased length of hospital stay. The NICE (National Institute of Clinical 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, Males- 69%, ESS- 7 ± 5) with a STOP BANG score of 3 or more underwent an overnight oximetry (32%; normal, 44%; mild, 15%; moderate and 9%; severe OSA). All moderate and severe OSA were recommended for CPAP therapy to facilitate their surgical procedures and for long term cardio-metabolic benefits. Diagnosis of moderate/severe OSA had an impact on the surgical decision (P < 0.0001, OR= 3.79, 95% 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 v/s non-day case, 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 v/s 9.6% in the normal/mild group.

Conclusion: Prevalence of OSA is high in pre surgical 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. An MDT approach and a dedicated CPAP pathway post diagnosis may help the clinicians and patients.

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 rapidly 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.

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 one million 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. The programme utilised the Model for Improvement as its QI framework and was delivered over a six 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. 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. 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.

Background: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are life-threatening complications of diabetes mellitus. However, limited data about DKA and HHS is available in patients with cancer. The current study aimed to determine characteristics and outcomes of patients with cancer who were admitted with DKA/HHS in a mid-size Canadian city.

Methods: Consecutive adult patients with an active cancer who were admitted with DKA or HHS from January 2008 to December 2020 in the city of Saskatoon, Saskatchewan, Canada were retrospectively evaluated. A univariate logistic regression analysis was performed to examine the correlation of various clinical variables with hospital mortality.

Results: During the study period 6,555 patients with diabetes and cancer were admitted in one of the three tertiary care hospitals. Among them 33 (0.5%) eligible patients with DKA or HHS with a median age of 60 years (range 36-94 years) were identified. In 36% of patients, DKA or HHS was the presenting manifestation of newly diagnosed diabetes. Of all patients, 66% developed DKA and 73% had an advanced cancer. Overall, 52% patients received a systemic cancer therapy prior to the admission, and 41% received steroids. Ten (42%) of 24 patients with an advanced cancer died compared to none of the 9 patients with an early-stage cancer (p=0.032). No clinical factors significantly correlated with hospital mortality.

Conclusions: Although DKA or HHS is uncommon in patients with diabetes and cancer, it is the manifestation of undiagnosed diabetes in about one-third of patients with cancer. It has been associated with a high hospital mortality rate in patients with advanced cancer.

Staphylococcus aureus bacteraemia (SAB) is a multi-system disease associated with a 20-25% mortality in the UK setting. Many patients with SAB are admitted acutely unwell and are treated by the general physician. This review summarises the key management steps that a general physician needs to be aware of when treating patients with SAB. Successful management relies on appropriate empirical and definitive antimicrobial therapy, effective source control, accurate risk stratification and timely identification of metastatic foci of infection, as well as exclusion of infective endocarditis, which can be present in up to 10% of patients with SAB.

The World Health Organization (WHO) has stated that antimicrobial resistance is one of the greatest health threats facing humanity and is responsible for significant morbidity and mortality, with a disproportionate impact on vulnerable groups of patients. The WHO set out its global action plan in 2015 and most countries have their own national plans, which take a whole system One Health approach that includes infection prevention and optimising the use of antimicrobials through stewardship programmes and diagnostics. In hospitals, antimicrobials are some of the most commonly prescribed medications, creating significant selection pressure for emerging resistance. Antimicrobial stewardship (AMS) in hospitals comprises a set of structured interventions that seek to optimise the benefits of treatments while limiting the harms. AMS is effective and has proven benefits such as improved outcomes and reduced spread of resistance in hospitals. This paper highlights key principles for antimicrobial prescribing and highlights recent evidence, some of which has been practice changing.

Hospital at Home (HaH) provides hospital-level care within patients' homes. With services expanding, a London HaH service embedded new junior doctor posts. Currently, gaps exist in the under- and postgraduate curriculum to develop clinical skills required to deliver care in this context. HaH simulation (HaH-SIM) was developed, through a multi-cycle QIP, to improve early-career doctors' confidence in providing care in this unfamiliar environment. Surveys before and after HaH-SIM assessed confidence in practical, clinical and communication skills; ranked concerns; rated sessions and gained qualitative feedback. 41 doctors participated over 2 years. It currently includes six low-fidelity stations and three high-fidelity stations. Confidence improved, particularly in managing end of life, decision-making around hospital admission and administering intravenous medications/fluids. High-fidelity scenarios, practical skills and prescribing stations were most highly rated. As HaH services expand, HaH-SIM is a feasible, effective and transferable way of improving early-career doctors' confidence and skills to provide care in patients' homes.

We report a case of a syndrome first described by French bacteriologist André Lemierre nearly 100 years ago. A young woman presented with fever, chest pain and arthralgia. Admission investigations revealed thrombocytopenia, cavitating pneumonia and an internal jugular vein thrombus. Blood cultures were positive for Fusobacterium necrophorum and Streptococcus constellatus. Respiratory failure developed within 48 h and was managed with high-flow nasal oxygen in a critical care setting. The investigation findings leading to diagnosis, as well as the antimicrobial and anticoagulation management strategies, are discussed. Lemierre's syndrome is rarely encountered by non-specialists, but a good outcome can be expected with prompt diagnosis and treatment.

Malaria remains a major global health problem. Transmission occurs in 84 countries across five continents, with almost 250 million cases and over 600,000 deaths each year. Primary and secondary care clinicians in the UK need to be alert to the prospect of malaria presenting in returning travellers. They must be aware of the signs of severe malaria, the need for prompt diagnosis and treatment, and the importance of seeking specialist advice. With emerging resistance, climate change and the roll-out of the first malaria vaccines, the landscape of malaria is changing. Here we discuss the past, present and future of malaria.