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Individualised therapeutic approach to the patient with atypical haemolytic-uraemic syndrome. 针对非典型溶血尿毒综合征患者的个性化治疗方法。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-10-04 DOI: 10.1016/j.clinme.2024.100250
Ivana Mikačić, Nikolina Marić

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.

非典型溶血性尿毒症综合征(aHUS)是一种罕见疾病,与不受控制的替代补体途径激活有关,会导致血栓性微血管病(TMA)。早期诊断和使用针对补体成分 C5 的单克隆抗体依库珠单抗(eculizumab)治疗对于改善预后、预防肾衰竭和死亡至关重要。目前的建议包括终生使用依库珠单抗治疗,但这种做法面临着高昂的治疗费用和因长期抑制补体而增加的感染风险等挑战。我们假设,根据患者个体反应定制个性化的依库珠单抗给药策略可以优化治疗、降低成本并提高安全性。我们通过介绍一位采用特定依库珠单抗治疗方法的患者来评估这一假设。患者的病情得到了明显改善,因此可以根据临床反应和药物水平监测情况逐步减少依库珠单抗的用量。在整个治疗过程中,对患者的补体活性和依库珠单抗水平进行了密切监测,结果显示,较低剂量的依库珠单抗仍能维持疗效,且无明显的 TMA 复发。该病例证明了在治疗 aHUS 时从固定治疗方案过渡到个性化用药策略的可行性。特别是考虑到不同基因突变之间复发风险的差异性,这种方法可以在维持疾病控制的同时减轻终身治疗带来的风险和成本。这种个性化治疗模式可能会对 aHUS 的治疗产生重大影响,使临床治疗符合患者的个体需求和经济考虑。进一步的研究应将药物药代动力学/药效学与临床/遗传学环境联系起来,以确定个体化患者治疗方法的里程碑。
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引用次数: 0
Differential effects of oral versus intravenous hydrocortisone and dexamethasone on capillary blood glucose levels in adult inpatients - a single centre study. 口服与静脉注射氢化可的松和地塞米松对成年住院患者毛细血管血糖水平的不同影响--一项单中心研究。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-10-04 DOI: 10.1016/j.clinme.2024.100249
Vaishali Limbachia, Ian Nunney, Daniel J Page, Hannah A Barton, Leena K Patel, Georgia N Thomason, Stephan L Green, Kieran F J Lewis, Ketan Dhatariya

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.

背景:皮质类固醇会升高血糖浓度;然而,口服和静脉注射哪种给药方式与住院患者血糖升高程度最大相关,目前仍不得而知。此外,根据给药途径的不同,一天中相关的高血糖模式是否也有所不同:这是一项单中心回顾性研究,研究对象是接受口服或静脉注射氢化可的松和地塞米松治疗的 384 名成年住院患者。研究收集了七天内毛细血管葡萄糖浓度和用药时间的数据。应用重复测量混合模型比较了口服和静脉注射皮质类固醇的葡萄糖浓度随时间的变化。采用自回归协方差结构来模拟重复测量之间的相关性。该模型根据年龄、性别、入院前糖尿病和/或入院前皮质类固醇状态进行了调整:口服氢化可的松和静脉注射氢化可的松在第一天和所有七天中均无明显差异(平均差分别为 0.17mmol/l (-1.39, 1.75),p=0.827;平均差分别为 0.20mmol/l (-0.61, 1.01),p=0.639)。口服或静脉注射地塞米松的患者在第一天或所有七天的平均血糖浓度均无差异(分别为平均差 0.41mmol/l (-0.55,1.38), p=0.404 和平均差 -0.09mmol/l (-1.05,0.87), p=0.855):本研究发现,口服和静脉注射氢化可的松和地塞米松对血糖水平的影响没有明显差异。强烈建议所有口服或静脉注射皮质类固醇的患者进行毛细血管血糖监测。
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引用次数: 0
Dynamics of minimal residual disease and its clinical implications in multiple myeloma: A retrospective real-life analysis. 多发性骨髓瘤极小残留病的动态变化及其临床意义:回顾性真实生活分析
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-10-01 DOI: 10.1016/j.clinme.2024.100252
Weiling Xu, Xinyue Liang, Shanshan Liu, Xingcheng Yi, Mengru Tian, Tingting Yue, Yingjie Zhang, Yurong Yan, Maozhuo Lan, Mengtuan Long, Nan Zhang, Jingxuan Wang, Xiaoxiao Sun, Rui Hu, Yufeng Zhu, Xintian Ma, Yue Cheng, Jiayi Xu, Yun Dai, Fengyan Jin

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.

背景:最小残留病灶(MRD)检测是量身定制多发性骨髓瘤(MM)治疗方案的有效方法。然而,在将其应用于日常实践之前,仍有几个主要问题需要解决,其中大部分问题源于 MRD 状态的动态性质。因此,了解 MRD 动态并提出其临床意义至关重要:我们回顾性分析了新诊断 MM(NDMM)患者的数据,这些患者在开始治疗后的多个时间点进行了基于流式细胞术的 MRD 检测。我们分析了检测不到的MRD(包括达到、持续时间和消失)对临床结果的影响:结果:在220名新确诊的MM患者中,无论基线风险因素如何,达到MRD-都会带来有利的结果(PFS和OS的P < 0.0001)。值得注意的是,MRD-持续时间≥12个月与病情进展/死亡或死亡风险降低83%(95% CI,0.09-0.34;P < 0.0001)或69%(95% CI,0.13-0.76;P = 0.0098)有关,而MRD-持续时间越长,预后越好。失去MRD-会导致较差的PFS(HR 0.01,95% CI 0-0.06,P < 0.0001)和OS(HR 0.03,95% CI 0-0.24,P = 0.0008)。大多数失去MRD-状态的患者(70%)都有高危细胞遗传学异常(HRCAs)。虽然MRD-与常规治疗反应(如≥CR或VGPR)在时间上不一致,但它比后者更能预测疾病进展或复发。最后,MRD状态的预测价值与基线风险因素(如HRCA、ISS或R-ISS分期)无关:结论:需要在治疗过程和随访中对 MRD 进行纵向评估,以监测疾病进展或复发,从而指导治疗决策。因此,目前正在进行一项前瞻性研究,以调查根据MRD状态的纵向变化进行MRD定制治疗的可行性和益处。
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引用次数: 0
Isolated cardiac sarcoidosis: A clinical challenge. 孤立性心脏肉样瘤病:临床挑战。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-19 DOI: 10.1016/j.clinme.2024.100245
Paul Njoku, Sumbal Rani, Orestis Paschalis, Emanuela Alati, Amit K J Mandal, Constantinos G Missouris

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.

肉样瘤病是一种以病因不明的非溃疡性肉芽肿为特征的炎症性疾病。孤立性心脏肉样瘤病 (ICS) 较为罕见,当心肌组织出现肉芽肿浸润而没有心外肉样瘤病的证据时就会发生。临床表现的异质性常常给诊断带来挑战,导致治疗延误。我们的病例强调了肉样瘤病的静止表现、早期治疗的重要性以及导致其诊断不足的诊断难题。
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引用次数: 0
British Cardiovascular Society survey of the provision and structure of cardiology multidisciplinary meetings in England. 英国心血管协会对英格兰心脏病学多学科会议的提供和结构进行的调查。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-12 DOI: 10.1016/j.clinme.2024.100243
B Liu, R A Archbold, J P Greenwood, S Ray, S S Hothi

Multidisciplinary meetings (MDMs) are central to clinical decision-making in many areas of cardiology. This study assessed current provision and structure of cardiology MDMs in England in comparison with national guidelines. British Cardiovascular Society (BCS) members were surveyed regarding frequency, core attendees, and organisational aspects of cardiology MDMs for myocardial revascularisation, endocarditis, heart failure, aortic valve, mitral and tricuspid valve MDMs, whether local, regional or outside of the region. Access to electrophysiology (EP), inherited cardiac conditions, and adult congenital heart disease (ACHD) MDMs was also assessed. Survey responses were received from 64 hospitals across England, of which 40 (62%) were secondary care centres and 24 (38%) were tertiary care centres. All units had access to revascularisation MDMs, although 6% of them (all in secondary care centres) lacked any surgical representation. Heart failure MDMs were available in 94% of centres, but 7% reported no attendance by a cardiologist with specialist interest in heart failure, and 23% reported no attendance by a device specialist. 61% of centres had access to dedicated endocarditis MDMs; however, 11% were not attended by a microbiologist or infectious disease physician, and 22% were not attended by a surgeon. Aortic valve MDMs were available in 69% of centres, while mitral and tricuspid valve MDMs were available in 56% of centres. One quarter of centres reported no access to EP, and one third of centres reported no access to ICC or ACHD MDMs. Substantial improvements in provision and structure of cardiology MDMs in England are needed in order to meet national guidance.

多学科会议(MDM)是心脏病学许多领域临床决策的核心。本研究对照国家指南,评估了目前英格兰心脏病学多学科会议的提供情况和结构。英国心血管学会(BCS)成员就心肌血管重建、心内膜炎、心力衰竭、主动脉瓣、二尖瓣和三尖瓣MDM的频率、核心与会者和组织方面接受了调查,无论是本地、区域性还是区域外。此外,还对电生理学 (EP)、遗传性心脏病和成人先天性心脏病 (ACHD) MDM 的使用情况进行了评估。调查回复来自英格兰的 64 家医院,其中 40 家(62%)为二级医疗中心,24 家(38%)为三级医疗中心。所有单位均可使用血管重建 MDM,但其中 6%(均为二级医疗中心)缺乏外科代表。94%的中心有心力衰竭MDM,但7%的中心没有心力衰竭专科心脏病专家,23%的中心没有器械专家。61%的中心有专门的心内膜炎 MDM,但11%的中心没有微生物学家或传染病医生参加,22%的中心没有外科医生参加。69%的中心有主动脉瓣MDM,56%的中心有二尖瓣和三尖瓣MDM。四分之一的中心称无法获得 EP,三分之一的中心称无法获得 ICC 或 ACHD MDM。英格兰需要大力改善心脏科 MDM 的供应和结构,以符合国家指南的要求。
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引用次数: 0
Approach to pancytopenia: From blood tests to the bedside. 治疗全血细胞减少症的方法:从血液检测到床边治疗。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-01 Epub Date: 2024-08-17 DOI: 10.1016/j.clinme.2024.100235
Shaun Chew, Majeed Kamangar

Pancytopenia is an uncommon abnormality detected on a full blood count. Features of presentation tend to be non-specific, and are due to impaired functions of the cell lines involved. These can include fatigue, infection and bleeding. However, the aetiology of pancytopenia is extensive. This narrative review aims to provide a minimally invasive diagnostic algorithm for generalist clinicians to approach pancytopenia, including investigations into the underlying aetiology, and when a referral to the haematologist is warranted for further investigations such as bone marrow aspiration and trephine biopsy.

全血细胞减少症是一种在全血细胞计数中发现的罕见异常。其表现特征往往没有特异性,是由于相关细胞系的功能受损所致。这可能包括疲劳、感染和出血。然而,全血细胞减少症的病因十分广泛。这篇叙述性综述旨在为全科临床医生提供一种微创诊断算法,以处理全血细胞减少症,包括对潜在病因的调查,以及何时需要转诊至血液科医生进行进一步调查,如骨髓抽吸和穿刺活检。
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引用次数: 0
Improving the systematic screening and documentation of mental capacity for patients with severe brain injury: The Mental Capacity Screening assessment tool (MCScreen). 改善严重脑损伤患者精神能力的系统筛查和记录:精神能力筛查评估工具(MCScreen)。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-01 Epub Date: 2024-08-20 DOI: 10.1016/j.clinme.2024.100236
Lynne Turner-Stokes, Karima Benaichouche-Motam, William Goodison, Adam Altaie, Alice Howard, Patrick McKnight, Jessie Alfonso

For patients who may lack capacity, the Mental Capacity Act 2005 requires capacity to be assessed for each decision at the time that treatment is offered, but this is not practical for every element of basic care and intervention delivered to patients undergoing rehabilitation following acquired brain injury, especially if their needs are changing. In this quality improvement project, we introduced a system for screening Mental Capacity and documentation to identify patients with a) largely intact cognition for whom capacity may be reasonably be presumed, and b) those in prolonged disorders of consciousness who clearly lacked capacity for all decisions. This enabled the multidisciplinary team to concentrate on evaluation of capacity in the third group who had more nuanced ability and required detailed assessment or support for decision-making. Two rounds of audit demonstrated that implementation improved the consistency of assessment and documentation. Multicentre roll-out of this approach is now required.

对于可能缺乏行为能力的患者,2005 年《心智能力法》要求在提供治疗时对每项决定的行为能力进行评估,但这对于为后天性脑损伤后接受康复治疗的患者提供基本护理和干预的每项内容来说都不切实际,尤其是当他们的需求在不断变化时。在这一质量改进项目中,我们引入了一套精神行为能力筛查系统和文件系统,以识别 a) 认知能力基本完好、可合理推定具有行为能力的患者,以及 b) 意识障碍持续时间较长、明显缺乏做出所有决定能力的患者。这样,多学科团队就能集中精力对第三类患者的能力进行评估,这些患者的能力更为细微,需要详细评估或决策支持。两轮审核结果表明,该方法的实施提高了评估和文件记录的一致性。现在需要在多中心推广这种方法。
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引用次数: 0
Severe measles with pneumonitis in an immunocompetent adult. 一名免疫功能正常的成年人患重症麻疹并发肺炎。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-01 Epub Date: 2024-08-30 DOI: 10.1016/j.clinme.2024.100239
Danielle Lee, Oliver Mercer, Varsha Halai, Laura Gill, Colin Macleod, Temi Lampejo

Measles is a highly contagious but vaccine-preventable airborne-transmitted viral infection of which there has been a recent resurgence of cases worldwide over the past year, including in countries such as the UK, which had previously successfully achieved endemic measles elimination through vaccination programmes. Measles is typically a self-limiting illness, but can rarely cause severe, life-threatening disease, particularly when complicated by respiratory or neurological involvement. These severe complications are not typically seen in the absence of immunosuppression. We describe a rare case of severe measles with pneumonitis in an immunocompetent adult necessitating admission to an intensive care unit (ICU).

麻疹是一种传染性极强但可通过疫苗预防的空气传播病毒感染,去年全球病例再次增多,包括英国等曾通过疫苗接种计划成功消灭麻疹流行的国家。麻疹通常是一种自限性疾病,但在极少数情况下会导致严重的、危及生命的疾病,尤其是在并发呼吸道或神经系统疾病时。在没有免疫抑制的情况下,通常不会出现这些严重并发症。我们描述了一例罕见的重症麻疹并发肺炎病例,患者为免疫功能正常的成年人,需要入住重症监护病房(ICU)。
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引用次数: 0
Improving quality in adult long covid services: Findings from the LOCOMOTION quality improvement collaborative. 提高成人长期护理服务的质量:LOCOMOTION 质量改进合作组织的研究结果。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-01 Epub Date: 2024-08-23 DOI: 10.1016/j.clinme.2024.100237
Julie Darbyshire, Trisha Greenhalgh, Nawar D Bakerly, Kumaran Balasundaram, Sareeta Baley, Megan Ball, Emily Bullock, Rowena Cooper, Helen Davies, Johannes H De Kock, Carlos Echevarria, Sarah Elkin, Rachael Evans, Zacc Falope, Cliodhna Flynn, Emily Fraser, Stephen Halpin, Samantha Jones, Rachel Lardner, Cassie Lee, Ashliegh Lovett, Victoria Masey, Harsha Master, Ghazala Mir, Adam Mosley, Jordan Mullard, Rory J O'Connor, Amy Parkin, Anton Pick, Janet Scott, Nikki Smith, Emma Tucker, Paul Williams, Darren Winch, Conor Wood, Manoj Sivan

The protracted form of COVID-19 known as 'long covid' was first described in 2020. Its symptoms, course and prognosis vary widely; some patients have a multi-system, disabling and prolonged illness. In 2021, ring-fenced funding was provided to establish 90 long covid clinics in England; some clinics were also established in Scotland and Wales. The NIHR-funded LOCOMOTION project implemented a UK-wide quality improvement collaborative involving ten of these clinics, which ran from 2021 to 2023. At regular online meetings held approximately 8-weekly, participants prioritised topics, discussed research evidence and guidelines, and presented exemplar case histories and clinic audits. A patient advisory group also held a priority-setting exercise, participated in quality meetings and undertook a service evaluation audit. The goal of successive quality improvement cycles aimed at changing practice to align with evidence was sometimes hard to achieve because definitive evidence did not yet exist in this new condition; many patients had comorbidities; and clinics were practically constrained in various ways. Nevertheless, much progress was made and a series of 'best practice' guides was produced, covering general assessment and management; breathing difficulties; orthostatic tachycardia and other autonomic symptoms; fatigue and cognitive impairment; and vocational rehabilitation. This paper summarises key findings with the frontline clinician in mind.

被称为 "长COVID "的COVID-19长期型于2020年首次被描述。其症状、病程和预后差异很大;一些患者会出现多系统、致残和长期患病的情况。2021 年,为在英格兰建立 90 个长焦病毒诊所提供了专项资金;苏格兰和威尔士也建立了一些诊所。由 NIHR 资助的 "LOCOMOTION "项目在全英范围内开展了一项质量改进合作项目,其中有 10 家诊所参与其中,该项目从 2021 年持续到 2023 年。在大约每 8 周举行一次的定期在线会议上,与会者确定主题的优先次序,讨论研究证据和指南,并展示示范病例和诊所审计。患者咨询小组还进行了优先事项设定工作,参加了质量会议,并进行了服务评估审核。接连不断的质量改进周期旨在改变实践,使之与证据保持一致,但这一目标有时很难实现,因为在这一新病症方面尚不存在确切的证据;许多患者有合并症;诊所受到各种实际限制。尽管如此,我们还是取得了很大进展,并编写了一系列 "最佳实践 "指南,内容涉及一般评估和管理、呼吸困难、正性心动过速和其他自主神经症状、疲劳和认知障碍以及职业康复。本文以一线临床医生为中心,总结了主要研究成果。
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引用次数: 0
Pandemics are here to stay: It's time for unity, both nationally and globally, in how we learn and respond. 大流行病将继续存在:现在是全国和全球团结一致,学习和应对的时候了。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-01 DOI: 10.1016/j.clinme.2024.100244
Ponnusamy Saravanan
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引用次数: 0
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