Clinical Medicine最新文献

Introduction: Clinical guidelines are an essential component of evidence-based medicine, and doctors have a responsibility to stay up-to-date. However, doctors' lack of awareness of publication of new guidelines may limit adherence and impact on patient care. This paper systematically reviews evidence on strategies used to make doctors aware of new/updated clinical guidelines.

Methods: Electronic databases (Medline, Embase via Ovid) were searched 2004-2024 for papers examining such strategies. Experimental, observational and qualitative studies were included. Data was extracted and critically analysed. PRISMA guidelines were followed.

Results: Fourteen relevant articles were identified; they were heterogeneous and the overall quality of evidence was poor. Two multifaceted interventions resulted in better adherence to some aspects of guidelines; some others showed improvements in self-reported awareness-related outcomes.

Conclusion: The evidence in this area is currently insufficient to recommend any strategy. Future research should focus on evaluation of interventions using appropriate study designs and objective outcome measures.

Patients with advanced, life-limiting illness might develop pain or breathlessness, requiring opioids. Opioid neurotoxicities, like sedation and delirium, overlap with signs of natural dying. Understanding natural dying is a core clinical skill for all healthcare professionals. It is important that clinicians accurately assess patients to distinguish opioid toxicity from natural dying. This is vital to ensure appropriate use of opioids and ensure patient comfort. Patients with opioid toxicity and no pain can usually be managed by reducing the opioid dose. In patients with opioid toxicity and pain, a change in opioid is often needed. In patients on regular opioids for symptom management, life-threatening opioid-induced respiratory depression (causing both a decrease in respiratory rate and oxygen saturations) is rare. Initial management is with stimulation and oxygenation. Low-dose intravenous naloxone (20-100 μg every 1-2 min) is rarely needed in this patient cohort. Specialist palliative care input should be sought.

Background: Mechanical thrombectomy (MT) has revolutionised the treatment of ischaemic stroke, leading to decreased rates of disability and mortality. However, many centres are unable to deliver a 24/7 service. Consequently, many patients who present in the non-operating hours are not considered for this treatment.

Methods: We conducted a quality improvement project (QIP) to provide patients presenting out of hours with access to MT. To achieve this, we designed a protocol to rescan those patients just before opening of the service to select the candidates based on the favourable perfusion criteria.

Results: Twenty-two out of the 39 patients included in the QIP had MT, which was not accessible before initiation of our protocol.

Conclusion: In stroke centres where 24/7 MT service is not available, patients with large vessel occlusion (LVO) stroke, who present in the non-operating hours, can get access to this treatment by consideration of early morning rescanning just before opening of the service.

Chronic liver disease (CLD) is increasingly prevalent and represents a major global health burden. Despite advances in diagnosis and management, both patients and non-hepatologist clinicians continue to hold misconceptions that adversely impact care quality and outcomes. Common myths include misunderstandings about the causes of liver disease, protein restriction in hepatic encephalopathy, and the risks of procedures like paracentesis. These beliefs often stem from limited hepatology exposure and unverified public health information. This narrative review identifies and categorises prevalent misconceptions in CLD, highlighting their real-world clinical consequences. By contrasting these myths with evidence-based guidance, we aim to promote awareness and improve multidisciplinary management. We advocate for targeted continuing medical education, structured care pathways, enhanced patient education and early transplant planning. Addressing these gaps is essential for delivering high-quality, equitable liver care and aligning clinical practice with current hepatology standards.

Background: This study provides an umbrella review to assess the methodological quality, biases and reliability of evidence regarding the factors influencing mortality in individuals with peripheral artery disease (PAD). It also offers a consolidated overview of the identified risk factors.

Methods: The review protocol was registered in PROSPERO (CRD42024615105). PubMed, Web of Science, the Cochrane Database of Systematic Reviews and Embase were used to search, covering the period from inception until September 2024. AMSTAR and GRADE were used to independently evaluate the methodological rigour and quality of the evidence.

Results: The review identified a total of 29 risk factors, of which 17 were significantly associated with higher mortality risk, while 12 did not show a notable association. The majority of the evidence was rated as low or very low quality, with only three risk factors being classified as having moderate-quality evidence. Key findings indicated that comorbidities such as chronic kidney disease, diabetes, underweight status, atrial fibrillation and depression were major contributors to higher mortality risk. In contrast, obesity and statin use were identified as being linked to a reduced risk of mortality. Additionally, blood biomarkers, including N-terminal pro-B-type natriuretic peptide, high-sensitivity C-reactive protein (CRP) and high-sensitivity cardiac troponin T, were identified as important predictors of mortality.

Conclusion: Comorbid conditions are key factors contributing to elevated mortality among individuals with PAD, whereas obesity and statin use are linked to reduced mortality risk. Additionally, blood biomarkers offer valuable insights into assessing mortality risk within this patient group.

Primary liver cancer is among the fastest-rising causes of cancer-related death in the UK, and the incidence in the UK has increased by almost 50% over the past decade. With increasing incidence of alcohol and metabolic-related liver disease, the rise in cases is expected to continue. While treatable and potentially curable in early stages, it often presents late, owing to the frequently silent nature of liver disease: it is thought that 50% of patients with HCC are unaware of their diagnosis. In the UK, risk of both developing of liver disease and of death from HCC is higher in areas of social deprivation. The recent publication of the NHS 10-year plan and its emphasis on tackling health inequality make this CME article particularly pertinent. With early detection of liver disease and HCC key for favourable outcomes, it is vital that healthcare professionals are aware of the aetiology and surveillance strategies for HCC to optimise liver disease, and to identify disease for curative treatment.

Musculoskeletal ultrasound plays an important role in facilitating diagnostic and therapeutic decisions in rheumatic diseases. This article discusses the utility of ultrasound in rheumatoid arthritis, spondyloarthropathy and crystal arthropathy. This article also highlights the implementation challenges and the emerging role of artificial intelligence in enhancing musculoskeletal ultrasound.

Aims/background: Prior research has demonstrated variation of opinion among physicians regarding management of oral anticoagulation (OAC) at the end of life (EOL). To investigate current practice and attitudes towards OAC at the EOL among secondary care clinicians in the UK, with particular emphasis on how comfortable clinicians feel in making these decisions.

Methods: A digital, self-report survey was designed, validated by experts in relevant fields and then distributed via email to secondary care clinicians in the UK involved in EOL care, utilising the existing mailing lists of national societies and research groups.

Results: 186 responses were received across 10 specialties and 47 NHS trusts. 56% of clinicians routinely seek advice from colleagues regarding these decisions. 53% of respondents reported having worried about the medico-legal implications of discontinuing OAC, 52% of whom reported that these worries influence their decision making. Patient characteristics are more commonly considered than anticipated life expectancy in deciding whether to suspend or continue OAC at the EOL (56.5% versus 43.5%), 83% of respondents would feel more confident in broaching this subject if national guidance existed.

Conclusions: Our findings demonstrate a significant variation in practice, a widely reported discomfort and a strong desire for professional guidance regarding the management of OAC at the EOL, among UK-based secondary care clinicians.

Infections are a major cause of morbidity and mortality in people with heart failure, accounting for approximately 25% of hospitalisations and deaths. Infection hospitalisations in people with heart failure last twice as long as other hospitalisations, with mortality rates after discharge being comparable to those seen after acute decompensated heart failure. Addressing this major challenge is essential to further improving the survival and quality of life of this population. However, very few studies have sought to understand why people with heart failure are predisposed to adverse infection outcomes and there are currently very few interventions that target this problem. In this review, we explore the underlying factors that may predispose individuals with heart failure to infection, highlight the impact of infections on outcomes, explore the potential strategies that may reduce adverse infection outcomes, and highlight future research priorities.

Acute myocarditis is an inflammatory condition of the heart muscle, most commonly caused by viral infections. Bacterial myocarditis, particularly due to non-typhoidal Salmonella (NTS), is exceptionally uncommon in immunocompetent individuals. We report a rare case of acute myocarditis secondary to Salmonella gastroenteritis in a woman in her early 20s, characterised by elevated cardiac biomarkers, positive stool cultures for Salmonella enterica, electrocardiographic changes and confirmatory cardiac magnetic resonance imaging. Management was conservative with anti-inflammatory monotherapy without antibiotic treatment, resulting in full clinical recovery with resolution of symptoms and normalisation of cardiac biomarkers. This case highlights a rare presentation of NTS-associated myocarditis and suggests that conservative management may be sufficient in selected cases. It underscores the importance of considering bacterial pathogens, including NTS, in the differential diagnosis of acute myocarditis, even in immunocompetent patients, and highlights the utility of multimodal imaging and individualised management strategies in achieving favourable outcomes in bacterial myocarditis.