Clinical Medicine最新文献

Two types of antibody could confuse the differential diagnosis of hypoglycaemia. One is insulin-binding autoantibodies (IAA), a double hit causing hypoglycaemia of insulin autoimmune syndrome (IAS, also known as Hirata's disease) as well as distorting measurements of insulin and/or C-peptide. The clinical manifestations and initial endocrine results in patients with IAS would mimic and masquerade as other common pathologies, as well as factitious hypoglycaemia in adults, children and newborns. The second type is non-IAA autoantibodies which, if fortuitously/incidentally present in patients with hypoglycaemia, could interfere with insulin and/or C-peptide immunoassay measurements, also confusing differential diagnosis. Currently, testing for antibodies (all classes/subclasses) by simple method such as polyethylene glycol (PEG) is not usually included among first-line investigations of hypoglycaemia, causing delayed diagnosis or diagnostic misapplication. Detection of antibodies, irrespective of their nature, warrants cautious and careful differential diagnosis, averting hospitalisation and curtailing unnecessary and expensive investigations.

Inpatient blood glucose monitoring (BGM) is prevalent, while healthcare costs and workforce demands are rising. We aimed to identify causes of unnecessary monitoring and assess effectiveness of targeted interventions, to maximise healthcare resources while prioritising patient safety. Clinical guidelines were established with the Endocrinology division. A root-cause analysis revealed different factors, which were targeted through the plan, do, study, act methodology. Education and raising awareness were provided to staff. Guidelines were summarised into emails and stickers. Data were collected after each intervention, to monitor inappropriate monitoring rates and adverse events (hypoglycaemia and hyperglycaemia). Results revealed a reduction of inappropriate BGM from 49.5% to 9.2% over 7 months, with no significant change in adverse events, with estimated annual savings of S$564,818.80 (£421,185.38) and 663.4 nursing hours hospital-wide. This highlights the effectiveness of clear guidelines, targeted multidisciplinary education to bridge gaps and empower staff to collaborate for patient-centred, high-value care.

Background: Metabolic syndrome is a constellation of cardiovascular risk factors and has been associated with a higher risk of mortality. Albuminuria was previously part of the criteria for metabolic syndrome. We investigated the associations of albuminuria and metabolic syndrome with all-cause mortality among patients with coronary artery disease.

Methods: We enrolled patients who had coronary angiography-proved coronary artery disease but no history of diabetes between 2009 and 2013. All patients underwent an oral glucose tolerance test to determine their glucose regulation state. Metabolic syndrome was determined using the criteria of National Cholesterol Education Program Adult Treatment Panel III. A spot urine sample was collected to determine the urinary albumin to creatinine ratio (UACR). Information on all-cause mortality was confirmed until March 2023. Cox-proportional hazard models were conducted to examine the associations of metabolic syndrome and albuminuria with all-cause mortality.

Results: A total of 823 patients with coronary artery disease were analysed. After a median follow-up period of 8.94 years, patients with metabolic syndrome had no significant difference in all-cause mortality compared with those without metabolic syndrome (adjusted hazard ratio [HR] 0.826, 95% CI 0.568-1.201, p = 0.317). In contrast, patients with albuminuria (UACR ≥ 30 mg/g) had an independently higher risk of all-cause mortality (adjusted HR 1.529, 95% CI 1.057-2.212, p = 0.024) compared with those who had normoalbuminuria.

Conclusions: Albuminuria was independently associated with all-cause mortality in patients with coronary artery disease but no history of diabetes, while the presence of metabolic syndrome was not.

Introduction: Adverse events (AEs) involve a safety problem and compromise the quality of care, but evidence on how they affect the prognosis of patients is limited.

Objective: In this study, the relationship between the presence of AEs and in-hospital mortality among patients is analysed, and their characteristics are compared.

Material and methods: An observational study with a cross-sectional design was conducted in 32 hospitals of varying complexity in the Community of Madrid. The clinical history of 9,111 patients was analysed. Patients who were in the emergency room and those admitted to psychiatric units or centres were excluded. All hospitalisations were reviewed using the Harvard Medical Practice Study methodology for the detection and characterisation of AEs. The association between in-hospital mortality and the number of AEs was analysed with two multivariate models via logistic regression: 1) an explanatory model adjusted for confounders and 2) a predictive model of in-hospital mortality. A descriptive analysis of the differential characteristics of the AE was performed for the patients who died.

Results: In-hospital mortality was 5%, with a higher incidence of AEs in patients who died (29.8% versus 11.9%; p < 0.005). The presence of 1 AE (OR [95% CI]: 2.1 [1.6 to 2.7]) or ≥3 AEs (2.4 [1.1 to 5.1]) significantly increased the odds of mortality. In addition, the increase in the number of AEs was a predictor of mortality without a dose-response effect. The AEs that were most associated with in-hospital mortality were those related to care (15.5%; p = 0.047), and 15.3% of the AEs that occurred during ward care contributed to in-hospital mortality.

Conclusion: There is an association between AEs and in-hospital mortality. The presence of at least 1 AE implies a critical event in the patient's prognosis without a dose-response effect. Reducing AEs related to care in patients with comorbidities is positioned as an efficient strategy for improving health outcomes.

Diabetes mellitus is an increasingly prevalent condition, with an estimated 1.3 billion people projected to be affected by 2050, and can reduce life expectancy by up to 20 years. Musculoskeletal complications are present in more than half of patients with diabetes and lead to significant morbidity and disability. Diabetes increases chronic inflammation, reduces anabolism and compromises blood supply to bones, muscles and joints. This can cause fibrosis of tendons and joints, impaired quality of bone and muscle production and, in some instances, local joint destruction. The risk is further increased in patients with overlapping metabolic syndrome. Musculoskeletal complications promote a sedentary lifestyle and worsen the trajectory of diabetes management. Here, we provide an update on the musculoskeletal manifestations of diabetes and their treatments since our review in 2015.

Background: Hepatocellular carcinoma (HCC) has high mortality, improved by early diagnosis. An integrated service was established to facilitate timely cancer surveillance.

Aims: Evaluate the utility of an early diagnostic centre (EDC) in diagnosis of liver cancer.

Methods: Retrospective analysis of patients at an EDC (2022-2024), compared to previous general clinic attendance. We investigated demographics, and liver disease aetiology and status. We tracked attendances and 'did-not-attend' rates, with sub-categorisation by time period. Assessments were categorised as ideal, optimal, sub-optimal or poor. Travel-costs and times were estimated.

Results: Patients attending the centre (315) were reviewed, with previous clinic reviews serving as comparator. The cohort was predominantly male (58.1%), mean age 53.93 ± 11.75 years, British-African descent (20.3%), from deprived backgrounds (68.8%) and non-cirrhotic (53.3%). The leading liver disease aetiology was hepatitis B (54.3%), followed by hepatitis C (20.6%) and alcoholic liver disease (11.4%). The EDC had a lower 'did-not-attend' rate (15.70% vs. 23.97% in general clinics), higher proportion of ideal assessments (99.7% vs. 51.1%), lower 'did-not-attend' costs (£11,695 vs. £119,796) and lower patient travel time (461 vs. 655 h) and cost (£3,249 vs. £9,765). Sub-stratification by COVID time periods showed 55 attendance failures pre-COVID, 146 during COVID and 401 post-COVID; compared to 73 'did-not-attends' in the EDC.

Conclusion: The EDC demonstrated clinical and economic efficiencies, improved surveillance and a reduction in costs compared to traditional clinics. These results underscore the potential of this model to enhance HCC surveillance, reduce costs and improve compliance.

Background: Therapeutic paracentesis (TP) is a key symptom-relieving intervention in refractory ascites. In response to rising demand, Nottingham University Hospitals NHS Trust was among the first UK centres to introduce a nurse-led, day-case TP service. This study evaluates the complications and mortality associated with this service.

Methods: Retrospective analysis was undertaken on patients with decompensated cirrhosis who underwent nurse-led day-case TP between 1 January 2017 and 31 December 2021. Clinical and outcome data were systematically collected.

Results: A total of 2,530 TP procedures were performed on 340 patients. Minor (self-limiting) complications occurred in 54 cases (2.1%). In 22 cases (0.9%), patients were admitted to hospital within 7 days of TP - the reasons for admission were bacterial peritonitis (n = 11), abdominal pain (n = 3), and leakage of ascitic fluid (n = 7) or bleeding (n = 1) from the puncture site. There were no cases of abdominal visceral perforation or in-hospital deaths among those admitted. About 290 patients were included in 1-year survival analysis. About 177 (61%) were alive 1 year after their first TP. The median time from first TP to death was 125 days (IQR 43-210). The 30- and 90-day mortality rates after TP were 21.0% and 33.1%, respectively. Older age (p < 0.001), hepatocellular carcinoma (p < 0.001) and ongoing alcohol use (p < 0.001) were independently associated with 1-year mortality.

Conclusion: Nurse-led, day-case TP is an effective and safe approach for managing refractory ascites in decompensated cirrhosis. Mortality remains high, particularly in patients with hepatocellular carcinoma and ongoing alcohol use.

Transplantation is both a cause of, and a therapy for, diabetes. Solid organ transplantation requires immunosuppressive regimens that frequently cause temporary or permanent hyperglycaemia, which can influence the outcome of allograft function and also increase cardiovascular mortality and morbidity. Post-transplant diabetes should be actively screened for and managed in the early post-transplant period, and should also be screened for long term in all solid organ transplant recipients. Transplantation of whole pancreas or pancreatic islets is a long-established therapy for people with type 1 diabetes (T1D) and severe hypoglycaemia unawareness. Both procedures may be done in association with other solid organ transplants, most commonly with kidney transplantation. They can induce insulin independence and improve allograft survival. Recently, stem cell-derived therapy for T1D has been shown to be possible in humans and is likely to become an important therapy for people living with T1D.