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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
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 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
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
Secondary hyperparathyroidism in chronic kidney disease: A narrative review focus on therapeutic strategy. 慢性肾病中的继发性甲状旁腺功能亢进症:以治疗策略为重点的叙述性综述。
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.2024.100238
Shin-Hwa Tsai, Wei-Chih Kan, Rong-Na Jhen, Yu-Ming Chang, Jsun-Liang Kao, Hsien-Yung Lai, Hung-Hsiang Liou, Chih-Chung Shiao

Chronic kidney disease (CKD) affects over 10% of the global population. One crucial complication of CKD is secondary hyperparathyroidism (SHPT), marked by elevated parathyroid hormone levels due to hyperphosphataemia, hypocalcaemia, and low active vitamin D from impaired renal function. SHPT increases risks of bone deformities, vascular calcification, cardiovascular events and mortality. This review examines SHPT treatment strategies in patients with CKD. First-line treatments include phosphate binders, vitamin D receptor activators and calcimimetics. When these fail, invasive options like parathyroidectomy (PTX) and thermal ablation are considered. PTX effectively reduces symptoms and improves radiological outcomes, outperforming medical treatment alone in reducing cardiovascular risk and mortality. Thermal ablation techniques, such as microwave, radiofrequency, laser or high-intensity focused ultrasound, offer less invasive alternatives with promising results. Future research should explore the molecular mechanisms of parathyroid gland hyperplasia and evaluate various treatments' impacts.

慢性肾脏病(CKD)影响着全球10%以上的人口。继发性甲状旁腺功能亢进症(SHPT)是慢性肾脏病的一个重要并发症,主要表现为高磷血症、低钙血症导致的甲状旁腺激素水平升高,以及肾功能受损导致的活性维生素 D 低下。SHPT会增加骨畸形、血管钙化、心血管事件和死亡的风险。本综述探讨了慢性肾脏病患者的 SHPT 治疗策略。一线治疗包括磷酸盐结合剂、维生素 D 受体激活剂和降钙剂。当这些治疗方法无效时,可考虑甲状旁腺切除术(PTX)和热消融术等侵入性治疗方案。PTX能有效减轻症状并改善放射学结果,在降低心血管风险和死亡率方面优于单纯的药物治疗。微波、射频、激光或高强度聚焦超声等热消融技术提供了创伤较小的替代方法,并取得了良好的效果。未来的研究应探索甲状旁腺增生的分子机制,并评估各种治疗方法的影响。
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引用次数: 0
Gliomas in adults: Guidance on investigations, diagnosis, treatment and surveillance. 成人胶质瘤:调查、诊断、治疗和监测指南》。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-01 Epub Date: 2024-09-02 DOI: 10.1016/j.clinme.2024.100240
Anna Lerner, Kieran Palmer, Tom Campion, Thomas O Millner, Emily Scott, Cressida Lorimer, Dimitrios Paraskevopoulos, Grainne McKenna, Silvia Marino, Rachel Lewis, Nick Plowman

Primary brain tumours are rare but carry a significant morbidity and mortality burden. Malignant gliomas are the most common subtype and their incidence is increasing within our ageing population. The diagnosis and treatment of gliomas involves substantial interplay between multiple specialties, including general medical physicians, radiologists, pathologists, surgeons, oncologists and allied health professionals. At any point along this pathway, patients can present to acute medicine with complications of their cancer or anti-cancer therapy. Increasing the awareness of malignant gliomas among general physicians is paramount to delivering prompt radiological and histopathological diagnoses, facilitating access to earlier and individualised treatment options and allows for effective recognition and management of anticipated complications. This article discusses evidence-based real-world practice for malignant gliomas, encompassing patient presentation, diagnostic pathways, treatments and their complications, and prognosis to guide management outside of specialist centres.

原发性脑肿瘤很少见,但发病率和死亡率却很高。恶性胶质瘤是最常见的亚型,其发病率在我国老龄人口中不断上升。胶质瘤的诊断和治疗涉及多个专科的大量工作,包括普通内科医生、放射科医生、病理学家、外科医生、肿瘤学家和专职医疗人员。在这一过程中的任何阶段,患者都可能因癌症或抗癌治疗的并发症而向急诊科求助。提高全科医生对恶性胶质瘤的认识,对于及时提供放射学和组织病理学诊断、促进尽早获得个性化治疗方案以及有效识别和处理预期并发症至关重要。本文讨论了以证据为基础的恶性胶质瘤真实世界实践,包括患者表现、诊断途径、治疗及其并发症和预后,以指导专科中心以外的治疗。
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引用次数: 0
Utilising accessible and reproducible neurological assessments in clinical studies: Insights from use of the Neurological Impairment Scale in the multi-centre COVID-CNS study. 在临床研究中使用可访问和可重复的神经学评估:多中心 COVID-CNS 研究中使用神经学损伤量表的启示。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-09-01 Epub Date: 2024-09-06 DOI: 10.1016/j.clinme.2024.100241
Ali M Alam, Glynn W Webb, Ceryce Collie, Sashini Mariathasan, Yun Huang, Orla Hilton, Rajish Shil, Katherine C Dodd, James B Lilleker, Craig J Smith, Ava Easton, Arina Tamborska, Rhys H Thomas, Nicholas W S Davies, Thomas M Jenkins, Michael Zandi, Laura Benjamin, Mark A Ellul, Tom Solomon, Thomas A Pollak, Tim Nicholson, Gerome Breen, Daniel J van Wamelen, Nicholas W Wood, Benedict D Michael

Reproducible and standardised neurological assessment scales are important in quantifying research outcomes. These scales are often performed by non-neurologists and/or non-clinicians and must be robust, quantifiable, reproducible and comparable to a neurologist's assessment. COVID-CNS is a multi-centre study which utilised the Neurological Impairment Scale (NIS) as a core assessment tool in studying neurological outcomes following COVID-19 infection. We investigated the strengths and weaknesses of the NIS when used by non-neurology clinicians and non-clinicians, and compared performance to a structured neurological examination performed by a neurology clinician. Through our findings, we provide practical advice on how non-clinicians can be readily trained in conducting reproducible and standardised neurological assessments in a multi-centre study, as well as illustrating potential pitfalls of these tools.

可重复和标准化的神经评估量表对于量化研究成果非常重要。这些量表通常由非神经病学家和/或非临床医生执行,因此必须稳健、可量化、可重复,并可与神经病学家的评估进行比较。COVID-CNS 是一项多中心研究,采用神经功能缺损量表 (NIS) 作为核心评估工具,研究 COVID-19 感染后的神经功能预后。我们调查了非神经科临床医生和非临床医生使用 NIS 的优缺点,并将其表现与神经科临床医生进行的结构化神经检查进行了比较。通过我们的研究结果,我们就如何在多中心研究中培训非临床医生进行可重复的标准化神经学评估提供了实用建议,并说明了这些工具的潜在缺陷。
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引用次数: 0
An integrated approach to neuroscience care: An innovative model to support the new integrated care system. 神经科学护理综合方法:支持新综合护理系统的创新模式。
IF 4.3 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-08-21 DOI: 10.1016/j.clinme.2024.100234
Michelle S Balaratnam, Fergus J Rugg-Gunn, Rachel Okin, Freya Powell, Stephen Prior, Panayiota Petrochilos, Dhiren Shivji, Salman Haider, Ali Alim-Marvasti, Arvind Chandratheva, Robert Simister, Charlie Lane, Roberto Macarimban, Diego Kaski, Bal Athwal, Rebecca Liu, Timothy Yates, Sanjeev Rajakulendran, Gerry Christofi, Jeremy Sandford, Alexis Ingram, Katherine Bluston, Caroline Weaver, Oluwaseun Odejide, George Glod, Gulsen Gungor, Edmund Nkrumah, Donal Markey, Gary Hotton, Katie Sidle, Jonathan Kennedy, Lisa Penniall, Helen Plum, Anthony Antoniou, Rakhee Prema, Nadia Jeffries, Carole Walters, Valerie L Stevenson, Malini Drysdale, Sabiha Tasnim, Shahrima Hussain, Lily Mackay, Ryan Baulk, Bianca IIii, David Egan, Adrian Capp, Patricia Turner, Christopher Turner

Integrated care systems join up health and care services, so that people have the support they need, in the right place, at the right time. The aims include improving outcomes in healthcare, tackling inequalities in access and enhancing productivity and value for money. This is needed for neuroscience care as the traditional delivery of neuroscience care is inefficient, outdated and expensive, and can involve complex referral pathways and long waiting times. In preparation for the formation of the integrated care system (ICS), a novel innovative collaboration across multiple NHS trusts developed across North Central London in 2021. We developed a model where neuroscience specialists engage in collaborative care with clinicians outside the specialist hospital setting. Pivotal to the pathway is a multidisciplinary meeting, and collaborative working enables joint clinical reviews, diagnostics and medication initiation. This innovative collaboration has already significantly improved access, addressed inequalities due to borough variation and enhanced the delivery and quality of neuroscience care in our ICS. It is a translatable model that can be adapted to suit other regions in the UK. It fulfils many of the objectives of the integrated care system and these benefits are seen without the need for significantly more resource.

综合护理系统将医疗和护理服务结合起来,使人们在正确的时间、正确的地点获得所需的支持。其目的包括改善医疗保健的成果,解决获取服务方面的不平等问题,以及提高生产率和性价比。神经科学护理需要这样做,因为传统的神经科学护理方式效率低、过时、昂贵,而且可能涉及复杂的转诊途径和漫长的等待时间。为迎接综合医疗系统的建立,2021 年,伦敦中北部多个国家医疗服务系统信托机构开展了一项新颖的创新合作。我们开发了一种模式,让神经科学专家与专科医院以外的临床医生共同参与协作护理。该路径的关键是召开多学科会议,通过合作实现联合临床审查、诊断和用药。这种创新性合作已大大改善了就医条件,解决了因行政区差异而造成的不平等问题,并提高了综合医疗服务系统的神经科学护理服务的交付和质量。这是一种可转化的模式,可根据英国其他地区的情况进行调整。它实现了综合医疗系统的许多目标,而且无需大幅增加资源就能获得这些益处。
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引用次数: 0
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Clinical Medicine
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