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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 3.6 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
Reducing the harm associated in treating hyperkalaemia with insulin and dextrose. 减少使用胰岛素和葡萄糖治疗高钾血症的危害。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-07-01 Epub Date: 2024-06-12 DOI: 10.1016/j.clinme.2024.100222
Sara Abou Sherif, Irene Katsaiti, Hannah Jebb, Serena Banh, Rachna Bedi, Jeremy Levy, David Thomas, Damien Ashby, Richard Corbett

Inpatient treatment of hyperkalaemia with insulin and dextrose can be complicated by iatrogenic hypoglycaemia. We sought to assess the incidence of hypoglycaemia in hospitalised patients with renal disease and assess the impact of the introduction of a local guideline incorporating the use of sodium zirconium cyclosilicate (SZC) for patients with moderate hyperkalaemia. After establishing a significant burden of hypoglycaemia in the initial observation period, a requirement for hourly capillary blood glucose monitoring (for up to 6 h) following the administration of insulin for hyperkalaemia was incorporated into the guidelines. The two-fold introduction of SZC alongside changes in patient care after the administration of insulin/dextrose resulted in more appropriate use of insulin/dextrose, as well as a significant (73%) reduction in the iatrogenic burden of hypoglycaemia (P = 0.04).

住院患者使用胰岛素和葡萄糖治疗高钾血症可能会因先天性低血糖而变得复杂。我们试图评估住院肾病患者的低血糖发生率,并评估引入当地指南对中度高钾血症患者使用环硅酸锆钠(SZC)的影响。在最初的观察期中,低血糖的发生率较高,因此在指南中加入了在使用胰岛素治疗高钾血症后每小时进行毛细血管血糖监测(最长 6 小时)的要求。在使用胰岛素/葡萄糖后,在改变患者护理方式的同时两次引入 SZC,从而更合理地使用胰岛素/葡萄糖,并显著(73%)减少了低血糖的先天性负担(P=0.04)。
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引用次数: 0
Vertebral body and spinal cord infarction in a pile-driver operator with fibrocartilaginous disc embolism. 一名患有纤维软骨椎间盘栓塞的打桩机操作员的椎体和脊髓梗塞。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-07-01 Epub Date: 2024-07-05 DOI: 10.1016/j.clinme.2024.100226
Sjx Murphy, Djh McCabe, R L O Donohoe, A J McCarthy

We describe the case of a male heavy machinery operator who presented from work with a rapidly evolving spinal cord syndrome. Spinal MRI revealed thoracic vertebral body and cord infarction and evolving mild disc prolapse attributed to fibrocartilaginous disc embolism (FCDE). FCDE should be considered as one of the aetiological mechanisms of acute spinal cord infarction in pile-driver/heavy machinery operators, especially in association with adjacent vertebral body infarction and intervertebral disc prolapse. Magnetic resonance imaging (MRI) changes may evolve, warranting early follow-up MRI in appropriate cases.

我们描述了一例男性重型机械操作员的病例,他下班后出现了迅速发展的脊髓综合征。脊柱磁共振成像显示,胸椎椎体和脊髓梗死以及不断演变的轻度椎间盘脱出归因于纤维软骨椎间盘栓塞(FCDE)。纤维软骨椎间盘栓塞应被视为打桩机/重型机械操作员急性脊髓梗死的病因之一,尤其是伴有邻近椎体梗死和椎间盘脱出时。磁共振成像(MRI)的变化可能会不断发展,因此在适当的情况下应及早进行磁共振成像随访。
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引用次数: 0
Pure red cell aplasia secondary to erythropoietin therapy. 继发于促红细胞生成素疗法的纯红细胞再生不良。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-07-01 Epub Date: 2024-07-17 DOI: 10.1016/j.clinme.2024.100229
Gwenno Mair Edwards, Abdulfattah A Alejmi

We report a case series of two patients with chronic kidney disease (CKD) who developed erythropoietin-induced pure red cell aplasia following a change in erythropoietin preparation. Both patients responded well to immunosuppressive treatments, but unfortunately developed severe infections as a result of being immunosuppressed.

我们报告了两例慢性肾脏病患者(CKD)的系列病例,他们在更换红细胞生成素制剂后出现了红细胞生成素诱导的纯红细胞再生障碍。这两名患者对免疫抑制治疗反应良好,但不幸的是,由于免疫抑制,他们都出现了严重的感染。
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引用次数: 0
Strongyloides stercoralis infection in the UK: A systematic review and meta-analysis of published cases. 英国的盘尾丝虫感染:对已发表病例的系统回顾和荟萃分析。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-07-01 Epub Date: 2024-07-14 DOI: 10.1016/j.clinme.2024.100227
Ali M Alam, Cansu Ozdemir, Nada Reza

Strongyloidiasis is a helminth infection where symptoms vary, and asymptomatic presentation is common. Chronic strongyloidiasis can cause a high mortality 'hyper-infection' in immunocompromised states. Understanding at risk populations and symptomology can guide screening and early treatment to reduce hyper-infection risk. A systematic review of studies describing patients in the UK with strongyloidiasis pooled a total of 1,308 patients. Weighted pooled prevalence (WPP) of asymptomatic cases was 27.7% (95% CI 17.1-39.5%, I2 = 92%, p < 0.01). At-risk populations included migrants, returning travellers and armed forces personnel. The most common symptoms reported were abdominal pain (WPP 32.1% (95% CI 20.5-44.8%), I2 = 93%, p < 0.01), rashes (WPP 38.4% (95% CI 13.1-67.7%), I2 = 99%, p < 0.01) and diarrhoea (WPP 12.6% (95% CI 6.7-19.9%), I2=70%, p = 0.03). Symptomatology varied with cohort characteristics. Although asymptomatic presentation is common, patients may present with abdominal pain, diarrhoea or rashes. A low threshold for screening symptomatic individuals in at-risk groups is required.

强直性脊柱炎是一种蠕虫感染,症状各不相同,无症状表现也很常见。在免疫力低下的状态下,慢性强直性脊柱炎可导致高死亡率的 "高感染"。了解高危人群和症状可以指导筛查和早期治疗,从而降低高感染风险。对描述英国强直性脊柱炎患者的研究进行了系统回顾,共汇总了 1308 名患者。无症状病例的加权汇总患病率(WPP)为27.7%(95%CI 17.1-39.5%,I2=92%,P2=93%,P2=99%,P2=70%,P=0.03)。症状随队列特征而变化。虽然无症状表现很常见,但患者也可能出现腹痛、腹泻或皮疹。对高危人群中无症状者的筛查阈值要低。
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引用次数: 0
Mandibular movement monitor provides faster, yet accurate diagnosis for obstructive sleep apnoea: A randomised controlled study. 下颌运动监测仪为阻塞性睡眠呼吸暂停提供更快更准确的诊断:随机对照研究。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-07-01 Epub Date: 2024-07-22 DOI: 10.1016/j.clinme.2024.100231
Sulaiman S Alsaif, Wendy Douglas, Joerg Steier, Mary J Morrell, Michael I Polkey, Julia L Kelly

Many patients with obstructive sleep apnoea (OSA) remain undiagnosed and thus untreated, and in part this relates to delay in diagnosis. Novel diagnostic strategies may improve access to diagnosis. In a multicentre, randomised study, we evaluated time to treatment decision in patients referred for suspected OSA, comparing a mandibular movement (MM) monitor to respiratory polygraphy, the most commonly used OSA detection method in the UK. Adults with high pre-test probability OSA were recruited from both northern Scotland and London. 40 participants (70 % male, mean±SD age 46.8 ± 12.9 years, BMI 36.9 ± 7.5 kg/m2, ESS 14.9 ± 4.1) wore a MM monitor and respiratory polygraphy simultaneously overnight and were randomised (1:1) to receive their treatment decision based on results from either device. Compared to respiratory polygraphy, MM monitor reduced time to treatment decision by 6 days (median(IQR): 13.5 (7.0-21.5) vs. 19.5 (13.7-35.5) days, P = 0.017) and saved an estimated 29 min of staff time per patient.

许多阻塞性睡眠呼吸暂停(OSA)患者仍未得到诊断,因此也未得到治疗,这在一定程度上与诊断延误有关。新的诊断策略可能会提高诊断率。在一项多中心随机研究中,我们对因疑似 OSA 而转诊的患者做出治疗决定所需的时间进行了评估,并将下颌骨运动(MM)监测仪与呼吸测谎仪(英国最常用的 OSA 检测方法)进行了比较。我们从苏格兰北部和伦敦招募了测试前可能性较高的 OSA 成人。40名参与者(70%为男性,平均年龄(±SD)为46.8±12.9岁,体重指数(BMI)为36.9±7.5 kg/m2,ESS为14.9±4.1)同时佩戴MM监测仪和呼吸测谎仪过夜,并随机(1:1)根据任一设备的结果决定是否接受治疗。与呼吸测谎仪相比,MM 监测仪将做出治疗决定的时间缩短了 6 天(中位数(IQR):13.5(7.0-21.5) vs. 19.5(13.7-35.5),P=0.017),并为每位患者节省了约 29 分钟的工作人员时间。
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引用次数: 0
The appropriateness of penicillin allergy de-labelling by non-allergist clinical ward teams. 非过敏学家临床病房团队对青霉素过敏进行去标签处理的适当性。
IF 3.6 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-07-01 Epub Date: 2024-06-27 DOI: 10.1016/j.clinme.2024.100225
Neil Powell, Shuayb Elkhalifa, Daniel Hearsey, Michael Wilcock, Jonathan Sandoe

Objectives: We aimed to assess the appropriateness of penicillin allergy (PenA) assessment conducted by clinical teams and to review the safety of subsequent exposure of these patients to penicillin.

Methods: Opportunistic, prospective observational study of usual clinical care, between 16 May 2023 and 14 August 2023, of inpatients with a PenA and requiring antibiotics, in a 750-bed hospital in England. To assess the appropriateness of management, PenA patients prescribed penicillins were grouped into risk categories using a validated antibiotic allergy assessment tool: eligible for de-label on history alone (direct de-label; DDL), eligible for direct oral challenge (DOC), high risk or unable to obtain history.

Results: Of the 123 patients admitted with a PenA (or sensitivity record) and exposed to a penicillin, data were collected for 50. Their PenA records were grouped follows: eligible for DDL 34 (68%), eligible for DOC 11 (22%), high risk 4 (8%) and unable to obtain history 1 (2%). In 14/50 (28%) patients there was no evidence of a current PenA assessment in the medical notes.

Conclusions: Using the allergy risk tool, most patients with PenA records were exposed to penicillin appropriately. However, patients meeting high-risk criteria were also exposed to penicillin when the tool excluded them. PenA assessment needs to be carried out with appropriate training and governance structures in place.

目的我们旨在评估临床团队进行青霉素过敏(PenA)评估的适当性,并审查这些患者随后接触青霉素的安全性:英国一家拥有 750 张病床的医院在 23 年 5 月 16 日至 23 年 8 月 14 日期间对需要使用抗生素的青霉素过敏住院患者的常规临床护理进行了机会性、前瞻性观察研究。为了评估管理的适当性,我们使用经过验证的抗生素过敏评估工具将开具青霉素处方的PenA患者分成了不同的风险类别:仅凭病史就符合去标签条件的(直接去标签;DDL)、符合直接口服挑战(DOC)条件的、高风险的或无法获得病史的:在 123 名有 PenA(或敏感性记录)并接触过青霉素的入院患者中,收集到了 50 名患者的数据。他们的 PenA 记录分类如下:符合 DDL 条件的 34 人(68%)、符合 DOC 条件的 11 人(22%)、高风险 4 人(8%)和无法获得病史的 1 人(2%)。14/50(28%)名患者的医疗记录中没有证据表明他们目前接受过 PenA 评估:结论:使用过敏风险工具,大多数有 PenA 记录的患者都适当地接触了青霉素。结论:大多数有 PenA 记录的患者都适当地接触了青霉素,但也有符合高风险标准的患者在工具排除的情况下接触了青霉素。在进行 PenA 评估时,需要进行适当的培训并建立相应的管理机构。
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引用次数: 0
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Clinical Medicine
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