Clinical Medicine最新文献

The management of ophthalmic conditions in pregnancy presents unique challenges that demand a nuanced approach. Significant knowledge gaps and practice variations persist, likely as a result of the infrequent nature of these issues in pregnancy, as well as the lack of crossover in the specialty training curriculum for both specialties. This commentary explores how multidisciplinary team (MDT) working can address these uncertainties to support shared decision-making and potentially improve outcomes in this vulnerable patient population. We highlight the need to involve ophthalmologists in obstetric MDTs, where appropriate, and the importance of establishing clear communication channels and referral pathways between both specialties and across hospitals in the region. We also share our experience of establishing these pathways locally, the feedback we have received from interdisciplinary educational initiatives to improve knowledge sharing, and possible future directions for this collaborative approach to help fill the evidence gap.

Introduction: Diabetes poses a significant global health challenge, with prediabetes serving as a critical phase for intervention to prevent or delay its progression. While evidence-based strategies have shown promise, their implementation within healthcare systems-particularly in low- and middle-income countries-remains a formidable challenge. This study shares preliminary findings from a regional quality improvement (QI) initiative aimed at identifying and managing prediabetes within Mexico's public healthcare framework.

Materials and methods: The Diabetes Prevention Squad program introduced a regional clinical service focusing on individuals at risk for diabetes or diagnosed with prediabetes in primary care settings. This QI initiative adopted a comprehensive approach, guiding participants from initial screening to engagement in a diabetes prevention program emphasizing lifestyle modifications. A cascade analysis was conducted, with results drawn from a pretest-posttest design comprising 14 visits over one year.

Results: Of the 1,256 participants screened, 90 were diagnosed with prediabetes. Among those who completed the intensive phase, 57% achieved prediabetes remission, and 37% experienced significant weight loss.

Conclusion: This QI initiative demonstrated a promising prediabetes remission rate among participants, underscoring the importance of a complete care pathway from screening to remission. Prediabetes remission and significant weight loss are vital outcomes in diabetes prevention. Integrating interventions focused on prediabetes remission into healthcare pathways is essential to reducing the diabetes burden.

Occupational exposures are a common and preventable cause of lung disease. About 1 in 6 cases of COPD and asthma worldwide are related to work. Early recognition of occupational lung disease improves outcomes. Doctors should ask about work history in patients with respiratory symptoms. This educational review article briefly outlines key clinical features, relevant to the general physician, of common occupational lung diseases seen in the UK. These conditions include work-related asthma, pneumoconioses, hypersensitivity pneumonitis and COPD. Referral to a specialist is recommended when an occupational cause is suspected. Most occupational lung diseases are preventable with adequate workplace safety measures and early medical attention.

Point of care ultrasound (POCUS) is becoming an increasing part of the assessment and management of patients within internal medicine. There is ample evidence confirming the diagnostic accuracy of POCUS in acutely unwell patients, but very little focus has been placed on the resource implications of introducing a POCUS service to a department. We provide here a complete evaluation of one year of reported scans in a district general hospital Acute Internal Medicine department, analysing the impact on departmental imaging requests following a POCUS scan. Between January and December 2023 a total of 467 scans yielded 572 individual reports, comprising thoracic, abdominal, urinary tract, deep vein thrombosis, echocardiogram and musculoskeletal scans. Of these reports, a departmental imaging request followed in only 154 (26.9%) of cases. Even when excluding thoracic ultrasound (which typically is not performed within radiology services), 188/321 cases (58.6%) did not require a subsequent departmental imaging request. For all individual scan types, in at least 45% of cases a departmental scan request did not follow. Where departmental requests were placed, in 34/154 (22.1%) cases they were for outpatient imaging rather than inpatient scans, meaning in total in only 120 (20.1%) instances did a POCUS scan lead to a subsequent inpatient imaging request. These data show that a dedicated internal medicine POCUS service will lead to significant reductions in inpatient radiology and echocardiography requests, rather than increasing the burden as previously hypothesised. They provide support to those departments considering setting up such a service.

The GMC's Medical Licensing Assessment (MLA) marks a pivotal moment in UK medical education: the 2025 graduating cohort will be the first required to pass this national exam before entering clinical practice. The accompanying MLA 'Content Map' lists 217 clinical presentations and 315 conditions - across 25 Areas of Clinical Practice, that students need to know by the end of the programmes. Whilst some medical educators may simply use this list to confirm whether timetabled teaching covers the material required others may use the list a driver for curriculum change and transformation. In the case of the latter, meaningful opportunity now exists for collaborative re-design of undergraduate programmes, comprising everything from removing terms such as 'pre-clinical' and 'clinical' through to promoting more integrated approaches to delivering medical education and developing clinical reasoning using more authentic, applied workplace-based learning activities.

The dominant paradigm in clinical medicine, public health and global health has been to split clinical practice, research, education, training and funding into communicable versus non-communicable diseases. This dichotomy was borne out of the context of colonialism and increasingly, not least during the recent COVID-19 pandemic, evidence suggests that a much closer relationship between these "disease siloes" would be beneficial, from risk factors to therapeutics. In this lecture, the synergies between communicable and noncommunicable diseases are explored in order to inform future policy and practice.

Scrub typhus, caused by Orientia tsutsugamushi, is a rickettsial infection transmitted by mite bites, often underdiagnosed in travellers from endemic regions. This case report describes a 65-year-old female with hypertension who developed severe scrub typhus after a trip to Sri Lanka. She presented with fever, myalgia, headache, fatigue, and a scabbed lesion. Initial tests showed neutrophilia, lymphocytopenia, and elevated liver enzymes. Malaria was ruled out, and empiric treatment with intravenous Tazocin was initiated. On day three, she developed Clostridium difficile infection, requiring a switch to oral vancomycin. By day five, her condition worsened with hypoxia, hypotension, oliguria, and renal failure. Chest X-ray revealed bilateral infiltrates and subsequently, she was transferred to critical care. Tests showed positive IgM test for O. tsutsugamushi. Oral doxycycline was started, resulting in rapid improvement. PCR confirmed scrub typhus. This case underscores the importance of early diagnosis and treatment with doxycycline in travellers from endemic areas presenting with febrile illness.

The quality of statistical reporting in biomedical journals remains insufficient despite the introduction of SAMPL Guidelines in 2015. These guidelines aim to improve clarity and accuracy but are underutilized by authors and editorial boards. Common deficiencies include unclear descriptions of statistical test purposes, inadequate reporting of effect sizes, poor analysis of assumptions, and limited consideration of outliers. Addressing these challenges requires broader adoption of SAMPL recommendations, improved statistical literacy among researchers and editors, and stronger editorial oversight. To enhance transparency and reliability in biomedical research, the SAMPL Guidelines should become standard practice, supported by targeted training and clear guidance for authors.

Objectives: To assess the impact of pilot transnasal endoscopy (TNE) services on workforce efficiency, allocated procedure times and patient tolerance of procedures. The aim was to also understand the challenges of setting up a TNE service.

Methods: Six-month data were collected from ten sites. Data captured included productivity, performance, workforce numbers, facilities and quality metrics. A patient survey was done to capture patients' experience. An eight Likert-style and open question survey was designed and used. Pilot sites were visited using a semi-structured interview process.

Results: About 30% of the pilot sites carried out the TNE service outside of the endoscopy unit. There is an overall 25% improvement in workforce efficiency with TNE. Of those patients who had both a TNE and an oesophagogastroduodenoscopy, 78% reported that having the TNE procedure was a better experience. All sites reported that they will continue providing TNE beyond the pilot period. Sites carrying out TNE reported a high satisfaction with the services. Overall satisfaction with the quality of TNE imaging was very high.

Conclusions: This multicentre pilot project shows evidence that the integration of TNE services has a positive impact in increasing capacity and patient satisfaction. This should set the scene for scaling this up on a wider capacity. TNE services, particularly with an introduction into outpatients, will improve service capacity in endoscopy, patients will tolerate the procedures more, national 2-week wait and Faster Diagnosis Standard targets will improve, and it is potentially more cost efficient overall.