Clinical Medicine最新文献

Background: Chronic obstructive pulmonary disease (COPD) contributes significantly to global morbidity and mortality and high economic burdens to healthcare systems. Emerging evidence suggests that sodium/glucose co-transporter-2 inhibitors (SGLT2i), beyond their use in type 2 diabetes mellitus (T2DM) and heart failure (HF), offer multifaceted immunomodulatory and anti-inflammatory effects which may offer positive outcomes in patients with COPD.

Objective: Investigate the impact of SGLT2i on inpatient outcomes - specifically, hospital length of stay (LOS), admission frequency, and use of acute non-invasive ventilation (NIV).

Methods: We conducted a 24-month retrospective observational study of adults with spirometry-confirmed COPD admitted to University Hospitals Coventry and Warwickshire between April 2022 and April 2024. Patients receiving SGLT2i for ≥30 days prior to study start formed the treatment group. Multivariable Poisson logistic regression was used to analyse the association between SGLT2i use and key outcomes, adjusting for demographics, disease severity, comorbidities and concurrent therapies.

Results: About 1,197 admissions of 627 patients met the inclusion criteria, with 32 patients (5%) prescribed SGLT2i. SGLT2i use was associated with a statistically significant 26% reduction in hospital LOS (95% CI 0.62-0.87; p ≤ 0.001), independent of co-existing HF or T2DM. However, there was no significant reduction in admission frequency (IRR 0.84, 95% CI: 0.62-1.09, p = 0.212) or acute NIV use (OR 2.62, 95% CI: 0.35-13.26, p = 0.277) among SGLT2i users.

Conclusions: SGLT2i therapy in COPD patients was associated with a significantly reduced hospital length of stay during exacerbations, regardless of underlying heart failure or diabetes status. However, no differences were observed in admission frequency or acute NIV utilisation. These findings support the hypothesis of a beneficial anti-inflammatory or cardiopulmonary effect of SGLT2i in COPD and warrant further investigation through prospective trials to explore their therapeutic role in this population.

Diabetes is a growing public health concern. Approximately 20% of acute NHS hospital beds are occupied by individuals with diabetes. Following the recent NICE (National Institute for Health and Care Excellence) updates, diabetes technologies are increasingly available in the NHS. Despite the benefits, they present challenges, eg unfamiliarity, insufficient education, and lack of confidence of general physicians who are increasingly likely to encounter people using these technologies, presenting with acute illnesses. This review aims to update the general physicians with diabetes technologies such as continuous glucose monitors, insulin pumps, hybrid closed loop systems and how to troubleshoot in acute illnesses, diabetes emergencies, perioperative management and radiological investigations. While it is important to develop consistent inpatient care pathways and out-of-hours support from diabetes teams, it is vital to enhance the knowledge and confidence of non-diabetes physicians. Further research is warranted to support the use of technology in inpatient settings and diabetes emergencies.

Diabetes mellitus and cardiac problems frequently coexist, posing significant challenges for both generalists and specialists. This article discusses the common cardiac manifestations of diabetes including coronary artery disease, heart failure and arrythmia, outlining specific diagnostic strategies and management in people with diabetes. We also discuss specific cardiovascular risk stratification strategies in diabetes, as well as glucose-lowering therapies with potential cardiovascular benefits. Ultimately a holistic approach is needed for individuals with co-existent cardiac problems and diabetes, tailoring management strategies to specific patient needs.

Invasive Salmonella infection is associated with high morbidity and mortality. It commonly affects patients who are immunocompromised or at extremes of age. We report an unusual case of a previously well 50-year-old gentleman with disseminated Salmonella infection. He presented with left hemispheric syndrome from an acute left middle cerebral artery stroke, complicated by status epilepticus requiring admission to the intensive care unit (ICU). Investigations revealed a large retroperitoneal abscess, and evidence of meningeal inflammation, ventriculitis and empyema. He required an abdominal drain for source control, and a prolonged course of culture-directed antibiotics, with eventual reduction in size of the retroperitoneal collection and interval decrease in frontal lobe gyral swelling. This case illustrates the importance of prompt diagnosis and timely initiation of antibiotic treatment to improve outcomes in invasive Salmonella infection, especially for those with meningitis.

Diabetic kidney disease (DKD) management has become increasingly complex. For non-specialists in diabetes or kidney disease, there are some basic standards of care that apply to all people with DKD. These include blood glucose optimisation, blood pressure management, renin-angiotensin-aldosterone system inhibitors (RAASi), lipid management and smoking cessation. There are also risk prediction tools, such as the Kidney Failure Risk Equation, that can be used to guide management and referral to specialist care. This article provides a broad overview of DKD and signposts the reader to useful resources for people with DKD.

Background: Systemic arterial air embolism is an uncommon but potentially fatal complication of CT-guided transthoracic lung biopsy. Although rare, it carries significant morbidity due to cerebral and coronary ischaemia.

Case presentation: We report two cases of systemic arterial air embolism occurring during CT-guided percutaneous lung biopsies. Both patients developed acute neurological deficits immediately following the procedure, attributed to cerebral air embolism. Imaging confirmed the presence of intracranial air in subarachnoid spaces. Neurological symptoms improved with supportive management, including oxygen administration and positioning. Histopathology in both cases revealed pulmonary adenocarcinoma.

Conclusion: These cases highlight the importance of prompt recognition and appropriate management of systemic air embolism. Risk mitigation strategies include careful patient positioning, minimisation of intrapulmonary pressure gradients, and maintenance of needle occlusion. Although rare, this complication must be anticipated by interventionalists and managed promptly to avoid permanent neurological damage.

Introduction: The UK faces a shortage of the medical workforce, which has prompted the NHS Long Term Workforce Plan to propose increases in medical training placements for resident doctors. Despite widespread agreement on the need for expansion, concerns persist regarding the ability of NHS trusts to provide adequate educator capacity, funding and infrastructure to support additional trainees. This study aims to identify the key barriers to trainee expansion as perceived by directors of medical education (DMEs) in England.

Methods: Between June and August 2024, a cross-sectional survey was conducted of DMEs responsible for overseeing medical education within NHS trusts in England. Respondents were asked both quantitative and qualitative questions to elucidate the relative importance of challenges to trainee expansion, and the data were analysed using descriptive statistics and thematic analysis.

Results: A total of 29 DMEs participated in the survey. The majority (93.1%) identified funding constraints as a critical barrier to trainee expansion, with many trusts struggling to meet financial demands despite NHS England salary contributions. Additionally, 89.7% of respondents reported inadequate educator capacity, and 72.4% cited a lack of suitable facilities to accommodate increased trainee numbers. Concerns were also raised regarding the ability to meet curricular and rotational requirements, particularly for higher specialty trainees.

Discussion: There is an urgent need for trainee number expansion, but this study highlights challenges in expanding medical training placements, including non-financial barriers. Addressing educator shortages, ensuring sufficient funding and improving facilities are essential to successfully implementing workforce expansion plans.

Chronic hepatitis B (CHB) is a leading cause of cirrhosis and hepatocellular carcinoma (HCC), with many patients remaining undiagnosed or undertreated despite effective vaccination and antiviral therapy. The 2025 European Association for the Study of the Liver (EASL) guidelines mark a shift towards biomarker-led, finite and personalised therapy, aiming for functional cure as sustained HBsAg loss. This review outlines updated recommendations on diagnosis, staging, treatment initiation and cessation, along with surveillance. Accurate interpretation of hepatitis B serological and virological markers remains central, with novel biomarkers, including quantitative HBsAg, HBcrAg and HBV RNA, enhancing disease stratification, guiding therapy and informing safe discontinuation of nucleos(t)ide analogues (NAs). The guidelines also emphasise the role of metabolic comorbidities, such as metabolic dysfunction-associated steatotic liver disease (MASLD), in accelerating fibrosis and increasing HCC risk. We summarise first-line NA and pegylated interferon options, monitoring requirements and surveillance strategies, highlighting common pitfalls such as under-recognition of at-risk patients with low viral load. Special considerations for pregnancy, immunosuppression and co-infections are addressed. Emerging therapies including RNA interference, core protein modulators and immunotherapeutics offer hope for finite, curative regimens. This article provides a practical, evidence-based guide for clinicians, trainees and allied health professionals to apply evolving recommendations in everyday practice.

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly non-alcoholic fatty liver disease (NAFLD), poses a significant challenge to public health. With the rise of obesity, hepatic steatosis now affects around a third of the UK population to varying degrees, frequently coexisting with other cardiometabolic conditions such as type 2 diabetes and ischaemic heart disease. Most patients with MASLD will be diagnosed in the community through investigation of deranged liver function tests or incidentally on abdominal ultrasound. It is therefore important for the general physician to be able to diagnose and risk-stratify MASLD, ensuring appropriate management and onward referral to hepatology for individuals with moderate or high risk of fibrosis.