Clinical Medicine最新文献

Anaphylaxis can induce life-threatening coagulopathy by releasing various mediators from activated mast cells. These mediators directly affect coagulation and fibrinolytic pathways, increasing the bleeding risk. Diagnosis and management of anaphylaxis-induced coagulopathy remain challenging. We report a unique case of a 44-year-old man with undiagnosed systemic mastocytosis who developed peanut-induced anaphylactic shock, resulting in cardiac arrest. Laboratory tests revealed elevated serum tryptase and severe coagulopathy. Thromboelastography, a point-of-care viscoelastic monitoring (VEM) test identified the presence of heparin-like anticoagulants within minutes. Bone marrow examination subsequently confirmed isolated mastocytosis. This case highlights the potential of VEM for rapid diagnosis and management of coagulopathy in patients with anaphylaxis, potentially aiding in the identification of mast cell degranulation in undifferentiated shock. We suggest that VEM should be considered in the investigation of patients with suspected anaphylaxis-induced coagulopathy.

Objectives: The value of the neutrophil-to-lymphocyte ratio (NLR) in predicting outcomes in patients hospitalised with community-acquired pneumonia (CAP) remains debated. This study evaluated whether NLR independently predicts clinical outcomes and enhances the predictive performance of the CURB-65 score in patients with CAP.

Methods: Data from CAP admissions at two Australian hospitals from 2018 to 2023 were analysed. NLR was calculated using admission neutrophil and lymphocyte counts. Patients were categorised into NLR >12 and NLR ≤12. Multilevel-multivariable regression models, adjusting for age, sex, Charlson index, CURB-65 score, Hospital Frailty Risk Score (HFRS) and C-reactive protein (CRP), assessed outcomes including length of stay (LOS), intensive care unit (ICU) admission and in-hospital mortality.

Results: Over 6 years, 7,862 patients with CAP were hospitalised (mean age 75.1 years, 54.6% male). Mean NLR was 12.6, with 2,877 (36.6%) patients having an NLR >12. Those with NLR >12 were older males with higher disease severity and Charlson index (p<0.05). Adjusted analyses showed that NLR >12 was independently associated with prolonged LOS (IRR=1.11, 95% CI 1.08-1.13, p<0.001), increased risk of ICU admission (adjusted odds ratio (aOR) =1.41, 95% confidence interval (CI) 1.06-1.88, p=0.019), and higher in-hospital mortality (aOR=1.27, 95% CI 1.06-1.53, p=0.009). The predictive ability of the CURB-65 score for in-hospital mortality was good (area under the curve (AUC) 0.68, 95% CI 0.66-0.70), while it was modest for the NLR (AUC 0.58, 95% CI 0.56-0.60). Incorporation of NLR to the CURB-65 score did not enhance its predictive ability (AUC 0.69, p>0.05).

Conclusions: NLR independently predicts adverse outcomes in patients hospitalised with CAP but does not improve the predictive performance of the CURB-65 score.

The World Health Organization (WHO) has stated that antimicrobial resistance is one of the greatest health threats facing humanity and is responsible for significant morbidity and mortality, with a disproportionate impact on vulnerable groups of patients. The WHO set out its global action plan in 2015 and most countries have their own national plans, which take a whole system One Health approach that includes infection prevention and optimising the use of antimicrobials through stewardship programmes and diagnostics. In hospitals, antimicrobials are some of the most commonly prescribed medications, creating significant selection pressure for emerging resistance. Antimicrobial stewardship (AMS) in hospitals comprises a set of structured interventions that seek to optimise the benefits of treatments while limiting the harms. AMS is effective and has proven benefits such as improved outcomes and reduced spread of resistance in hospitals. This paper highlights key principles for antimicrobial prescribing and highlights recent evidence, some of which has been practice changing.

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.

Malaria remains a major global health problem. Transmission occurs in 84 countries across five continents, with almost 250 million cases and over 600,000 deaths each year. Primary and secondary care clinicians in the UK need to be alert to the prospect of malaria presenting in returning travellers. They must be aware of the signs of severe malaria, the need for prompt diagnosis and treatment, and the importance of seeking specialist advice. With emerging resistance, climate change and the roll-out of the first malaria vaccines, the landscape of malaria is changing. Here we discuss the past, present and future of malaria.

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.

We report a case of a syndrome first described by French bacteriologist André Lemierre nearly 100 years ago. A young woman presented with fever, chest pain and arthralgia. Admission investigations revealed thrombocytopenia, cavitating pneumonia and an internal jugular vein thrombus. Blood cultures were positive for Fusobacterium necrophorum and Streptococcus constellatus. Respiratory failure developed within 48 h and was managed with high-flow nasal oxygen in a critical care setting. The investigation findings leading to diagnosis, as well as the antimicrobial and anticoagulation management strategies, are discussed. Lemierre's syndrome is rarely encountered by non-specialists, but a good outcome can be expected with prompt diagnosis and treatment.

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.

What tests to send and when? This article examines the evidence for common microbiological tests and discusses their limitations and interpretation. Urine tests, surface swabs, blood cultures and screening swabs are all discussed in the context of a fictional clinical case.