Clinical Medicine最新文献

Peripheral intravenous cannulation (PIVC) is an essential skill for newly qualified foundation doctors. It has high failure rates, resulting in care delays, pain and infection. We explored the perceived impact of ultrasound-guided PIVC (US-PIVC) training on confidence when performing difficult-access PIVC. We surveyed 88 foundation doctors to evaluate their perceptions of US-PIVC. Each cohort of participants was given two sessions over a 2-month period. Confidence was assessed using electronic questionnaires through 5-point Likert scales and free text responses. Confidence when performing PIVC with difficult access, regardless of US, increased significantly following the course (p < 0.01). This was also true regarding confidence when performing US-PIVC (p < 0.01.). Key themes identified included technical skills, confidence and clinical utility.

There are significant variations in discharge post-diabetes-related ketoacidosis (DKA) hospitalisation, yet there is a paucity of research to understand or minimise the reasons. This quality improvement project (QIP) aimed to identify reasons for post-DKA discharge delays and assess intervention efficacy. Utilising the Digital Evaluation of Ketosis and Other Diabetes-related Emergencies (DEKODE) model, data from 177 DKA episodes from January 2021 to September 2023 across three hospitals were analysed. Factors affecting discharge were investigated through a plan, do, study, act (PDSA) methodology. While interventions focused on optimising data collection and refining discharge guidelines, no significant reduction in DKA duration or length of stay was observed. Findings highlight post-DKA hospitalisation's multifaceted nature and the limited impact of simple interventions. Collaborative efforts and further research are necessary to develop effective strategies for expedited discharge and improved patient care. This study's comprehensive tracking and analysis tool offers valuable insights for future interventions in managing DKA-related hospitalisations.

This case illustrates a rare cause of facial pain due to glossopharyngeal neuralgia in a 66-year-old male patient. Imaging confirmed an aneurysm of the cervical internal carotid artery as the cause; the aneurysm itself, likely secondary to an elongated styloid process (Eagle's syndrome). The imaging findings and management options are discussed below.

Background: Contemporary observations indicate insufficient quality in the reporting of statistical data. Despite the publication of the SAMPL guidelines in 2015, they have not been widely adopted. The aim of this article is to highlight the incorporation of SAMPL Guidelines in the statistical reviews of articles related to clinical medicine, as well as the changes implemented by authors in revised manuscripts as a result of such guidance. An additional objective is to provide recommendations for biomedical journals regarding the necessity of integrating SAMPL Guidelines into their daily practices.

Methods: The study incorporated 100 selected statistical reviews of original clinical medicine articles from 8 biomedical journals, conducted between 2016 and 2023. Each of these reviews suggested specific SAMPL Guidelines to be implemented in the revised manuscript. It was evaluated which specific SAMPL Guidelines were most frequently enforced and what changes resulted from their implementation.

Results: Seventy-five percent of the manuscripts in question garnered acceptance following a solitary round of statistical evaluation. Among the most frequently recommended and subsequently implemented SAMPL Guidelines by the authors are a more thorough description of the purpose of the applied statistical tests (65%), indication of the practical significance of the obtained results, including calculation of relevant effect size measures (64%), analysis of assumptions necessary for the application of specific statistical tests (58%), and consideration of the impact of outlier values on the obtained results (34%).

Conclusion: To improve the quality of statistical reporting in biomedical journals, greater emphasis should be placed on implementing SAMPL Guidelines.

Background: The long-COVID syndrome is characterised by a plethora of symptoms. Given its social and economic impact, many studies have stressed the urgency of proposing innovative strategies other than hospital settings. In this double-blinded, randomised, case-control trial, we investigate the effects of sulphur thermal water inhalations, rich in H₂S, compared to distilled water inhalations on symptoms, inflammatory markers and nasal microbiome in long-COVID patients.

Methods: About 30 outpatients aged 18-75 with positive diagnosis for long-COVID were randomised in two groups undergoing 12 consecutive days of inhalations. The active group (STW) received sulphur thermal water inhalations whereas the placebo group received inhalations of sterile distilled non-pyrogenic water (SDW). Each participant was tested prior treatment at day 1 (T0), after the inhalations at day 14 (T1) and at 3 months follow-up (T2). At each time point, blood tests, nasal swabs for microbiome sampling, pulmonary functionality tests (PFTs) and pro-inflammatory marker measure were performed.

Results: The scores obtained in the administered tests (6MWT, Borg score and SGRQ) at T0 showed a significant variation in the STW group, at T1 and T2. Serum cytokine levels and other inflammatory biomarkers reported a statistically significant decrease. Some specific parameters of PFTs showed ameliorations in the STW group only. Changes in the STW nasopharyngeal microbiota composition were noticed, especially from T0 to T2.

Conclusions: Inhalations of sulphur thermal water exerted objective and subjective improvements on participants affected by long-COVID. Significant reduction of inflammatory markers, dyspnoea scores and quantitative and qualitative changes in the nasopharyngeal microbiome were also assessed.

Atypical haemolytic-uraemic syndrome (aHUS) is a rare disease associated with uncontrolled activation of the alternative complement pathway, leading to thrombotic microangiopathy (TMA). Early diagnosis and treatment with eculizumab, a monoclonal antibody targeting the complement component C5, are crucial to improve outcomes and prevent renal failure and mortality. Current recommendations include lifelong eculizumab therapy, yet this practice presents challenges including high treatment costs and increased infection risks from prolonged complement inhibition. We hypothesise that a personalised eculizumab dosing strategy tailored to individual patient responses could optimise therapy, reduce costs and improve safety. This hypothesis was evaluated through a presentation of a patient who was managed with a specific eculizumab treatment approach. The patient's condition improved significantly, allowing for a gradual reduction in eculizumab dosage based on clinical response and drug level monitoring. Throughout treatment, the patient's complement activity and eculizumab levels were closely monitored, showing that lower doses maintained therapeutic efficacy without evident TMA recurrence. This case supports the feasibility of transitioning from fixed regimens to personalised dosing strategies in managing aHUS. Such approaches could mitigate the risks and costs associated with lifelong therapy while maintaining disease control, especially considering the variability in relapse risk among different genetic mutations. This personalised treatment model might significantly impact the management of aHUS, aligning clinical care with individual patient needs and economic considerations. Further research should relate drug pharmacokinetics/pharmacodynamics to clinical/genetic setting to identify milestones of individual patient treatment approach.

Background: Corticosteroids raise blood glucose concentrations; however, it remains unknown which form of administration, oral or intravenous, is associated with the greatest degree of blood glucose rise in hospitalised patients. Furthermore, it is not known whether the pattern of the associated hyperglycaemia throughout the day differs depending on the route of administration.

Methods: This was a single centre retrospective study of 384 adult inpatients receiving oral or intravenous hydrocortisone and dexamethasone. Data on capillary glucose concentrations and time taken over 7 days were collected. A mixed model for repeated measures was applied to compare changes in glucose concentration over time for oral and intravenous corticosteroids. An auto-regressive covariance structure was employed to model correlations between repeated measurements. This was adjusted for age, sex, pre-admission diabetes, and/or pre-admission corticosteroid status.

Results: No significant difference was found between oral and intravenous hydrocortisone on day 1 or across all 7 days (mean difference 0.17 mmol/L (-1.39, 1.75), p = 0.827, and mean difference 0.20 mmol/L (-0.61, 1.01), p = 0.639 respectively). There were no differences in mean glucose concentrations between those on oral or intravenous dexamethasone on day 1 or across all 7 days (mean difference 0.41 mmol/L (-0.55, 1.38), p = 0.404 and mean difference -0.09 mmol/L (-1.05,0.87), p = 0.855, respectively).

Conclusion: This study found that oral and intravenous administration of hydrocortisone and dexamethasone do not have a significantly differing impact on blood glucose levels. Capillary glucose monitoring is strongly recommended in all individuals who are on either oral or intravenous corticosteroids.

Background: Minimal residual disease (MRD) testing is a promising approach to tailor the treatment of multiple myeloma (MM). However, several major concerns remain to be addressed before moving it into daily practice, most of which stem from the dynamic nature of the MRD status. Thus, it is crucial to understand the MRD dynamics and propose its clinical implications.

Methods: We retrospectively analysed the data of patients with newly diagnosed MM (NDMM) who had flow cytometry-based MRD tests at multiple time points after initiation of therapy. The impact of undetectable MRD (including attainment, duration and loss) on clinical outcomes was analysed.

Results: In a cohort of 220 patients with NDMM, attainment of MRD^- offered favourable outcomes (P < 0.0001 for both progression-free survival (PFS) and overall survival (OS)), regardless of baseline risk factors. Notably, MRD^- duration ≥12 months was associated with an 83 % (95 % confidence interval (CI), 0.09-0.34; P < 0.0001) or 69 % (95 % CI, 0.13-0.76; P = 0.0098) reduction in risk of progression/death or death, while the longer MRD^- was sustained, the better the outcome was. Loss of MRD^- led to poor PFS (hazard ratio (HR) 0.01, 95 % CI 0-0.06, P < 0.0001) and OS (HR 0.03, 95 % CI 0-0.24, P = 0.0008). Most patients (70 %) who lost MRD^- status carried high-risk cytogenetic abnormalities (HRCAs). While MRD^- was temporally inconsistent with conventional therapeutic responses (eg ≥ complete remission or very good partial response), it predicted disease progression or recurrence more robustly than the latter. Last, the predictive value of the MRD status was independent of baseline risk factors (eg high-risk cytogenetic abnormality, International Staging System (ISS) or Revised (R-)ISS staging).

Conclusions: Longitudinal assessment of MRD during the treatment course and follow-up is required for monitoring disease progression or relapse, to guide treatment decisions. Accordingly, a prospective study is currently ongoing to investigate the feasibility and benefit of the MRD-tailored therapy according to the longitudinal changes of the MRD status.

Sarcoidosis is an inflammatory disease characterised by non-caseating granulomas of unclear aetiology. Isolated cardiac sarcoidosis (ICS) is rare and occurs when there is granulomatous infiltration of myocardial tissue without evidence of extracardiac sarcoidosis. The heterogeneity in clinical manifestations often presents a diagnostic challenge which leads to delays in treatment initiation. Our case highlights the often quiescent presentation of ICS, the importance of early treatment and the diagnostic challenges that contribute to its underdiagnosis.