Pub Date : 2024-07-01Epub Date: 2024-07-14DOI: 10.1016/j.clinme.2024.100228
Samuel James Reynolds, Suresh Kumar Chhetri
Motor neuron disease (MND) is an uncommon but invariably fatal condition, with a median survival of 24-48 months from symptom onset. Although there is no cure at the moment, early diagnosis is crucial to enable timely access to multidisciplinary care, and enrolment in clinical trials utilising investigational therapies. Unfortunately, diagnostic delays remain common, and the average delay between symptom onset and diagnosis is 12 months. Large numbers of specialist referrals have been suggested as a key contributor to diagnostic delays. We conducted a retrospective review of the medical records of patients diagnosed with MND in Lancashire and South Cumbria, to investigate whether large numbers of specialty referrals are a common occurrence in MND. Our review identified that 35% of patients with MND were seen by two or more specialties before being referred to neurology. This rose to 49% when patients with bulbar onset disease were considered. 9% of cases saw three or more specialists. There was a statistically significant correlation between the number of specialist referrals and delays in neurology referral. We hope our findings will increase awareness of the importance of early neurology referral in the diagnosis of MND and promote the use of the MND Red Flag tool as a means of identifying patients in need of prompt neurological evaluation.
{"title":"Specialist referrals and diagnostic delays in motor neurone disease: Mapping patients' journey through hoops and hurdles in healthcare.","authors":"Samuel James Reynolds, Suresh Kumar Chhetri","doi":"10.1016/j.clinme.2024.100228","DOIUrl":"10.1016/j.clinme.2024.100228","url":null,"abstract":"<p><p>Motor neuron disease (MND) is an uncommon but invariably fatal condition, with a median survival of 24-48 months from symptom onset. Although there is no cure at the moment, early diagnosis is crucial to enable timely access to multidisciplinary care, and enrolment in clinical trials utilising investigational therapies. Unfortunately, diagnostic delays remain common, and the average delay between symptom onset and diagnosis is 12 months. Large numbers of specialist referrals have been suggested as a key contributor to diagnostic delays. We conducted a retrospective review of the medical records of patients diagnosed with MND in Lancashire and South Cumbria, to investigate whether large numbers of specialty referrals are a common occurrence in MND. Our review identified that 35% of patients with MND were seen by two or more specialties before being referred to neurology. This rose to 49% when patients with bulbar onset disease were considered. 9% of cases saw three or more specialists. There was a statistically significant correlation between the number of specialist referrals and delays in neurology referral. We hope our findings will increase awareness of the importance of early neurology referral in the diagnosis of MND and promote the use of the MND Red Flag tool as a means of identifying patients in need of prompt neurological evaluation.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100228"},"PeriodicalIF":3.6,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11345289/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141603341","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01Epub Date: 2024-05-06DOI: 10.1016/j.clinme.2024.100217
Ahmed Abouelazm, Kirollos Philops, Amr Amine, Yahia Golam
Statin-induced immune-mediated necrotising myopathy (IMNM) is an inflammatory myopathy that can present as proximal muscle weakness and, in some cases, as dysphagia and respiratory distress. In this report, we present a case of statin-induced IMNM in a 78-year-old male. The patient had significantly high levels of creatinine kinase and myoglobinuria and experienced gradual weakness in the proximal muscles for 1 month after initiating a 20 mg dose of Atorvastatin 10 months before admission. Rapid clinical improvement was observed with the use of high-dose glucocorticoids in conjunction with methotrexate.
{"title":"Statin-induced, immune-mediated necrotising myopathy triggered by malignancy successfully treated with immunosuppression.","authors":"Ahmed Abouelazm, Kirollos Philops, Amr Amine, Yahia Golam","doi":"10.1016/j.clinme.2024.100217","DOIUrl":"10.1016/j.clinme.2024.100217","url":null,"abstract":"<p><p>Statin-induced immune-mediated necrotising myopathy (IMNM) is an inflammatory myopathy that can present as proximal muscle weakness and, in some cases, as dysphagia and respiratory distress. In this report, we present a case of statin-induced IMNM in a 78-year-old male. The patient had significantly high levels of creatinine kinase and myoglobinuria and experienced gradual weakness in the proximal muscles for 1 month after initiating a 20 mg dose of Atorvastatin 10 months before admission. Rapid clinical improvement was observed with the use of high-dose glucocorticoids in conjunction with methotrexate.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100217"},"PeriodicalIF":3.6,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11108855/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140860165","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01Epub Date: 2024-05-04DOI: 10.1016/j.clinme.2024.100214
Benjamin Page, Sam Waddy
Spinal epidural abscess is a rare but serious condition with poor outcomes. It's classic triad of new back pain, neurological deficit and fever is only present in 15% of cases at presentation and is initially misdiagnosed in 75-89%.6,7 Delaying treatment is associated with worse outcomes. Delirium is itself a risk factor for mortality but the disturbance in cognition and memory can also complicate clinical assessment.1-5 We present a case of delirium caused by, and obscuring, a spinal epidural abscess. This case highlights the difficulties in diagnosing spinal epidural abscesses, the need for a high index of suspicion for the condition and timely action to minimise morbidity. In addition, it demonstrates the value of treating unexplained delirium as an emergency and the danger of diagnostic premature closure. Finally, the importance of persistent clinical examination of the confused and non-cooperative patient.
{"title":"A case of spinal epidural abscess concealed by delirium in a young man.","authors":"Benjamin Page, Sam Waddy","doi":"10.1016/j.clinme.2024.100214","DOIUrl":"10.1016/j.clinme.2024.100214","url":null,"abstract":"<p><p>Spinal epidural abscess is a rare but serious condition with poor outcomes. It's classic triad of new back pain, neurological deficit and fever is only present in 15% of cases at presentation and is initially misdiagnosed in 75-89%.<sup>6,7</sup> Delaying treatment is associated with worse outcomes. Delirium is itself a risk factor for mortality but the disturbance in cognition and memory can also complicate clinical assessment.<sup>1-5</sup> We present a case of delirium caused by, and obscuring, a spinal epidural abscess. This case highlights the difficulties in diagnosing spinal epidural abscesses, the need for a high index of suspicion for the condition and timely action to minimise morbidity. In addition, it demonstrates the value of treating unexplained delirium as an emergency and the danger of diagnostic premature closure. Finally, the importance of persistent clinical examination of the confused and non-cooperative patient.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100214"},"PeriodicalIF":3.6,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11108811/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140847675","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01Epub Date: 2024-04-20DOI: 10.1016/j.clinme.2024.100207
Nader Al-Shakarchi, Jaya Upadhyay, Ivan Beckley, Faye Gishen, Anna Di Iorio, Robert Stephens, Sarah Clegg, Fiona C Lampe, Amitava Banerjee
Background: Digital health, data science and health informatics are increasingly important in health and healthcare, but largely ignored in undergraduate medical training.
Methods: In a large UK medical school, with staff and students, we co-designed a new, 'spiral' module (with iterative revisiting of content), covering data science, digital health and evidence-based medicine, implementing in September 2019 in all year groups with continuous evaluation and improvement until 2022.
Results: In 2018/19, a new module, 'Doctor as Data Scientist', was co-designed by academic staff (n = 14), students (n = 23), and doctors (n = 7). The module involves 22 staff, 120 h (43 sessions: 22 lectures, 15 group and six other) over a 5-year curriculum. Since September 2019, 5,200 students have been taught with good attendance. Module student satisfaction ratings were 92%, 84%, 84% and 81% in 2019, 2020, 2021 and 2022 respectively, compared to the overall course (81%).
Conclusions: We designed, implemented and evaluated a new undergraduate medical curriculum that combined data science and digital health with high student satisfaction ratings.
{"title":"Design, implementation and evaluation of a spiral module combining data science, digital health and evidence-based medicine in the undergraduate medical curriculum: A mixed methods study.","authors":"Nader Al-Shakarchi, Jaya Upadhyay, Ivan Beckley, Faye Gishen, Anna Di Iorio, Robert Stephens, Sarah Clegg, Fiona C Lampe, Amitava Banerjee","doi":"10.1016/j.clinme.2024.100207","DOIUrl":"10.1016/j.clinme.2024.100207","url":null,"abstract":"<p><strong>Background: </strong>Digital health, data science and health informatics are increasingly important in health and healthcare, but largely ignored in undergraduate medical training.</p><p><strong>Methods: </strong>In a large UK medical school, with staff and students, we co-designed a new, 'spiral' module (with iterative revisiting of content), covering data science, digital health and evidence-based medicine, implementing in September 2019 in all year groups with continuous evaluation and improvement until 2022.</p><p><strong>Results: </strong>In 2018/19, a new module, 'Doctor as Data Scientist', was co-designed by academic staff (n = 14), students (n = 23), and doctors (n = 7). The module involves 22 staff, 120 h (43 sessions: 22 lectures, 15 group and six other) over a 5-year curriculum. Since September 2019, 5,200 students have been taught with good attendance. Module student satisfaction ratings were 92%, 84%, 84% and 81% in 2019, 2020, 2021 and 2022 respectively, compared to the overall course (81%).</p><p><strong>Conclusions: </strong>We designed, implemented and evaluated a new undergraduate medical curriculum that combined data science and digital health with high student satisfaction ratings.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100207"},"PeriodicalIF":3.6,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11091512/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140853958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.clinme.2024.100219
Ponnusamy Saravanan
{"title":"Doing simple things well can achieve significant benefits.","authors":"Ponnusamy Saravanan","doi":"10.1016/j.clinme.2024.100219","DOIUrl":"10.1016/j.clinme.2024.100219","url":null,"abstract":"","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":"24 3","pages":"100219"},"PeriodicalIF":3.6,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11258704/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141466706","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-01DOI: 10.1016/j.clinme.2024.100201
Ponnusamy Saravanan
{"title":"Editorial: Learnings from all walks of medical practice.","authors":"Ponnusamy Saravanan","doi":"10.1016/j.clinme.2024.100201","DOIUrl":"10.1016/j.clinme.2024.100201","url":null,"abstract":"","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":"24 2","pages":"100201"},"PeriodicalIF":4.4,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11091438/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140904473","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-01Epub Date: 2024-02-29DOI: 10.1016/j.clinme.2024.100030
Gordon W Stewart
This review concerns the rare, acquired, usually iatrogenic, high-anion-gap metabolic acidosis, pyroglutamic acidosis. Pyroglutamate is a derivative of the amino acid glutamate, and is an intermediate in the 'glutathione cycle', by which glutathione is continuously synthesized and broken down. The vast majority of pyroglutamic acidosis cases occur in patients on regular, therapeutic doses of paracetamol. In about a third of cases, flucloxacillin is co-prescribed. In addition, the patients are almost always seriously unwell in other ways, typically with under-nourishment of some form. Paracetamol, with underlying disorders, conspires to divert the glutathione cycle, leading to the overproduction of pyroglutamate. Hypokalaemia is seen in about a third of cases. Once the diagnosis is suspected, it is simple to stop the paracetamol and change the antibiotic (if flucloxacillin is present), pending biochemistry. N-acetyl-cysteine can be given, but while the biochemical justification is compelling, the clinical evidence base is anecdotal.
{"title":"Pyroglutamate acidosis 2023. A review of 100 cases.","authors":"Gordon W Stewart","doi":"10.1016/j.clinme.2024.100030","DOIUrl":"10.1016/j.clinme.2024.100030","url":null,"abstract":"<p><p>This review concerns the rare, acquired, usually iatrogenic, high-anion-gap metabolic acidosis, pyroglutamic acidosis. Pyroglutamate is a derivative of the amino acid glutamate, and is an intermediate in the 'glutathione cycle', by which glutathione is continuously synthesized and broken down. The vast majority of pyroglutamic acidosis cases occur in patients on regular, therapeutic doses of paracetamol. In about a third of cases, flucloxacillin is co-prescribed. In addition, the patients are almost always seriously unwell in other ways, typically with under-nourishment of some form. Paracetamol, with underlying disorders, conspires to divert the glutathione cycle, leading to the overproduction of pyroglutamate. Hypokalaemia is seen in about a third of cases. Once the diagnosis is suspected, it is simple to stop the paracetamol and change the antibiotic (if flucloxacillin is present), pending biochemistry. N-acetyl-cysteine can be given, but while the biochemical justification is compelling, the clinical evidence base is anecdotal.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100030"},"PeriodicalIF":3.6,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11091441/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140021087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-01Epub Date: 2024-02-16DOI: 10.1016/j.clinme.2024.100031
Sarita Jacob, George I Varughese
Diabetic retinopathy and nephropathy share pathophysiological mechanisms and there is a defined correlation between the severity of both these microvascular complications from suboptimal glycaemic control. The reno-protective properties offered by sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists should be applicable to diabetic retinopathy as well. However, in patients with pre-existing diabetic retinopathy, sudden improvement in glycaemic control is well documented to cause early worsening of the changes in the retina that is usually transient. This paradoxical phenomenon tends to occur with longer duration of diabetes, higher HbA1c at the outset, rapid improvement of glucose levels and the magnitude of HbA1c reduction with addition of more agents to tighten metabolic control. Interestingly, this progression of pre-existing diabetic retinopathy is not quite observed with newer sodium-glucose co-transporter-2 inhibitors. This article discusses potential further areas of future research where mechanisms of renal protection can be translated to the retina.
{"title":"Optimising renal risk parameters in type 2 diabetes mellitus: Perspectives from a retinal viewpoint.","authors":"Sarita Jacob, George I Varughese","doi":"10.1016/j.clinme.2024.100031","DOIUrl":"10.1016/j.clinme.2024.100031","url":null,"abstract":"<p><p>Diabetic retinopathy and nephropathy share pathophysiological mechanisms and there is a defined correlation between the severity of both these microvascular complications from suboptimal glycaemic control. The reno-protective properties offered by sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists should be applicable to diabetic retinopathy as well. However, in patients with pre-existing diabetic retinopathy, sudden improvement in glycaemic control is well documented to cause early worsening of the changes in the retina that is usually transient. This paradoxical phenomenon tends to occur with longer duration of diabetes, higher HbA1c at the outset, rapid improvement of glucose levels and the magnitude of HbA1c reduction with addition of more agents to tighten metabolic control. Interestingly, this progression of pre-existing diabetic retinopathy is not quite observed with newer sodium-glucose co-transporter-2 inhibitors. This article discusses potential further areas of future research where mechanisms of renal protection can be translated to the retina.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100031"},"PeriodicalIF":3.6,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11091439/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139899515","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-01Epub Date: 2024-02-16DOI: 10.1016/j.clinme.2024.100027
Tanguy Espejo, Henk B Riedel, Sebastian Messingschlager, Wolfram Sonnleitner, John Kellett, Mikkel Brabrand, Tim Cooksley, Roland Bingisser, Christian H Nickel
Aim: To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team.
Method: Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team.
Results: 4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility.
Conclusion: Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability.
{"title":"Predictive value and interrater reliability of mental status and mobility assessment in the emergency department.","authors":"Tanguy Espejo, Henk B Riedel, Sebastian Messingschlager, Wolfram Sonnleitner, John Kellett, Mikkel Brabrand, Tim Cooksley, Roland Bingisser, Christian H Nickel","doi":"10.1016/j.clinme.2024.100027","DOIUrl":"10.1016/j.clinme.2024.100027","url":null,"abstract":"<p><strong>Aim: </strong>To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team.</p><p><strong>Method: </strong>Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team.</p><p><strong>Results: </strong>4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility.</p><p><strong>Conclusion: </strong>Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability.</p>","PeriodicalId":10492,"journal":{"name":"Clinical Medicine","volume":" ","pages":"100027"},"PeriodicalIF":4.4,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11091407/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139899516","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}