Clinical Medicine最新文献

Pregnancy is associated with a wide range of cutaneous changes. Some are physiological and triggered by normal hormonal fluctuations during pregnancy. There are also a small number of pathological pruritic eruptions that exclusively occur during pregnancy, known as pregnancy-specific dermatoses (PSDs). In patients presenting with a PSD, features often include severe pruritus and characteristic inflammatory skin changes differing in onset, morphology and configuration. This article gives an overview of benign dermatological changes during pregnancy and the most important presentations of PSDs in order of prevalence: atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis and pustular psoriasis of pregnancy. Importantly, we outline how a resident physician can identify these disorders, how to initiate management and when a specialty referral for further investigations and monitoring of the mother and unborn fetus is warranted.

The emergent field of interventional bronchoscopy provides an alternative approach for the diagnosis and management of a range of respiratory conditions. Within malignant disease, robotic navigational bronchoscopy provides a stable platform to sample small and difficult to reach pulmonary nodules, while malignant central airway obstruction can be managed through transcopic stent insertion. A range of therapeutic modalities have been developed for benign disease, which provide alternatives to standard therapy, particularly in the context of endobronchial valves for chronic obstructive pulmonary disease, and bronchial thermoplasty for asthma, while transbronchial cryoexcision lung biopsy offers a non-surgical option for undiagnosed interstitial lung disease. With a rich pipeline of technology being developed through robust clinical trial processes, the field of interventional bronchoscopy will continue to grow to become an invaluable asset, not only to the field of respiratory medicine, but to the general physician.

Occupational exposures are a common and preventable cause of lung disease. About one in six cases of chronic obstructive pulmonary disease (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.

Pneumothorax is defined as air in the pleural space and is characterised by chest pain and breathlessness. It is commonly divided into spontaneous and non-spontaneous subtypes based on the underlying mechanism. Chest X-ray is the most common investigation to diagnose and monitor pneumothorax, but CT-chest is being increasingly used to aid decision making in complex cases and to investigate an underlying lung disease. There should be a low threshold to investigate for an underlying familial or catamenial cause in suspected cases. Treatment for pneumothorax is based on clinical condition and symptoms of the patient rather than the size of pneumothorax. Conservative care can be offered to minimally symptomatic primary spontaneous pneumothorax patients, while needle aspiration, ambulatory Heimlich valve device and chest drain remain the interventional treatment options. Chest drain is a common treatment for patients with secondary spontaneous pneumothorax due to poor lung reserve. Recurrence after spontaneous pneumothorax is common and smoking cessation reduces the risk of future recurrence in active smokers. Surgical treatment with pleurodesis ± bullectomy should be considered for treatment of suitable patients with persistent air leak and for pneumothorax recurrence prevention in high-risk populations.

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. While 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 redesign 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.

Sarcoidosis is a complex disease of unknown origin, primarily affecting the lungs but capable of involving almost any organ. Diagnosis is challenging due to the lack of specific markers and requires assessment of clinical features, careful imaging, exclusion of other conditions and, ideally, a tissue biopsy demonstrating non-necrotising granulomas. Over 90% of patients have pulmonary involvement, presenting with symptoms like dry cough and breathlessness, along with systemic signs such as fever and weight loss. Extrapulmonary manifestations occur in about 30% of cases and can affect any organ, including the heart, nervous system and eyes. Management involves a multidisciplinary approach with some patients requiring immunosuppressive and antifibrotic therapies. Despite generally good outcomes, sarcoidosis can lead to significant morbidity and mortality, particularly from pulmonary and cardiac complications. Emerging treatments like infliximab and nintedanib offer hope for refractory cases, although they carry risks of serious infections and other side effects.

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 underutilised 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.

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 programme 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 programme emphasising lifestyle modifications. A cascade analysis was conducted, with results drawn from a pretest-posttest design comprising 14 visits over 1 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.

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 1 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 that, 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.