Clinical Medicine最新文献

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.

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.

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.

Advanced therapies (AT), encompassing biologics and small molecules, are a common and important treatment for inflammatory bowel disease (IBD). However, these treatments pose a risk of reactivating latent infections and therefore require pre-treatment infection screening, but compliance with this screening has previously been reported to be poor. Clinical nurse specialists (CNS) and pharmacists play a key role in facilitating this screening and safely initiating AT, but are understaffed compared to national standards. Through retrospective review of electronic patient records at St George's University Hospital, a tertiary IBD centre in London, UK, we evaluated the impact of staffing on rates of compliance with screening and time from prescription to administration of AT (TAT). 1,035 patients with IBD treated with an AT were identified, and we found a significant correlation between increased CNS staffing and improved screening compliance, as well as a numerical reduction in the TAT. Incidental findings were relatively low, with 8% of patients presenting positive results, all of whom had clinical risk factors. The study advocates for increased staffing and resources in IBD services to enhance patient safety and treatment efficacy.

Primary ciliary dyskinesia (PCD) is a rare genetic disorder characterised by abnormal function of motile cilia. The condition usually manifests in early life with neonatal distress, chronic sinopulmonary disease and organ laterality disorders. In adults, it is an underdiagnosed cause of bronchiectasis as well as subfertility. This review provides an overview of PCD for clinicians. We discuss its aetiology, its presentation, how it is diagnosed and its multidisciplinary clinical management.

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 non-communicable diseases are explored in order to inform future policy and practice.