Clinical Medicine最新文献

In contrast with other major disease groups, mortality from liver disease in the UK has been increasing in recent decades. Patients with liver disease have a symptom burden comparable to those with other life-limiting conditions but, due to a range of factors including uncertain disease trajectory and perceived complexity, provision of high-quality palliative care is sometimes limited for this patient group. There has been growing recognition of this, with work to improve prognostication and advance care planning for patients with chronic liver disease.

Paediatric chronic liver diseases are rare, but are increasingly encountered in adult practice as survival improves and more adolescents transition to adult services. Adult physicians must be familiar with these conditions, recognise complications and implement high-quality management of these conditions to provide safe, effective care. Autoimmune liver disease in children includes autoimmune hepatitis, autoimmune sclerosing cholangitis and primary sclerosing cholangitis, with distinct serological and clinical profiles. Cholestatic disorders such as progressive familial intrahepatic cholestasis and Alagille syndrome present additional challenges, often impacting multiple organs and requiring multidisciplinary care. Many patients will enter adulthood having undergone liver transplant, requiring long-term immunosuppression and, where relevant, family planning advice. Recognition of extra-hepatic manifestations, metabolic complications and mental health issues is essential to holistic management. This article outlines the key paediatric liver diseases relevant to adult practice, highlighting key elements of care and long-term considerations for this unique and often complex patient population.

Genetic liver diseases are individually rare but collectively significant causes of chronic liver dysfunction in adults. Conditions such as Wilson disease, hereditary haemochromatosis and alpha-1 antitrypsin deficiency often present with vague or non-specific features, including fatigue, abnormal liver enzymes or extrahepatic manifestations. These features are easily misattributed to more common hepatic or systemic conditions, particularly in acute or general medical settings. Early recognition and investigation are crucial, as targeted treatments can prevent progression to end-stage liver disease, and timely referral enables cascade testing for at-risk relatives. With increasing access to genomic testing through systems such as the NHS Genomic Medicine Service in England, generalists play a key role in integrating genomics into routine care. This article provides a practical update on recognising, investigating and managing rare genetic liver conditions, aiming to support earlier diagnosis, better patient outcomes, and improved use of genomic services in frontline practice.

Hepatitis C virus (HCV) remains a significant global health challenge, affecting an estimated 50 million people. In most cases, infection becomes chronic, with long-term risks including liver cirrhosis and hepatocellular carcinoma. Beyond hepatic complications, many individuals experience non-specific symptoms such as fatigue and cognitive impairment, which can significantly impact daily functioning. The introduction of direct-acting antivirals has transformed HCV management, offering cure rates above 95% with minimal side effects. However, HCV continues to disproportionately affect marginalised groups, including people who inject drugs, migrants, and those experiencing homelessness. With targeted support and inclusive care pathways, these populations can be effectively treated. In this review, we examine the latest developments in HCV care, including current treatment protocols, emerging clinical trial data, and future directions - particularly the pursuit of a preventative vaccine. Achieving HCV elimination will require not only continued therapeutic innovation, but also a commitment to equality and equity in healthcare delivery.

Background: Anaphylaxis is a severe, potentially life-threatening allergic reaction that requires urgent and effective management. The UK Resuscitation Council updated its advanced life support (ALS) guidelines for anaphylaxis in 2021, emphasising early and repeated adrenaline administration, intravenous (IV) fluid use, and reduced reliance on antihistamines and steroids.

Methods: A retrospective audit was carried out to compare the management of anaphylaxis at two English NHS hospitals, namely the University Hospital of North Midlands (UHNM) and the Shrewsbury and Telford Hospital (SATH), before (2018) and after (2022/23) the ALS guideline implementation. Adherence to NICE anaphylaxis guidance was also assessed.

Results: Data from 272 patients revealed significant improvements in recognition of anaphylaxis in 2022 compared with 2018 (70.8% vs. 50%; p=0.001). The use of adrenaline and IV fluids increased, whereas the use of antihistamines and steroids declined, aligning with the new guidance. Tryptase measurement (checked in 45% of patients) and specialist referral rates (67% at UHNM vs. 3% at SATH; p=0.0001) remained suboptimal at both centres. A case example highlights the risks of misdiagnosis and adrenaline overuse in patients with recurrent urticarial presentations.

Conclusion: Anaphylaxis management in these centres has changed in keeping with the new ALS guidelines, although antihistamines and steroids were still used in the acute management of around 50% of the patients. Adrenaline overuse may be an unintended consequence of the guideline, which needs monitoring. There may have been some improvement in anaphylaxis recognition, but serum tryptase measurement and referral to allergy specialists remain poor.

Antiretroviral therapy (ART) has transformed infection by human immunodeficiency virus (HIV), from almost universally fatal into a manageable condition. With expansion of ART coverage, global HIV-related deaths have fallen by 69% since their peak in 2004. ART is highly effective at reducing HIV transmission; people with fully suppressed viral load do not transmit the virus sexually. Treatment is becoming easier, with better tolerated drugs, reduced side effects and combination tablets. Here, we review the changing landscape of HIV epidemiology and treatment, focusing on the impact of ART and the latest developments in long-acting injectable HIV therapy. These agents offer the potential for treatment and prevention without requiring patients to take daily tablets, including for multidrug-resistant infections. HIV epidemic control is on the horizon for many countries due highly effective prevention programmes. However, emerging funding challenges due to geopolitical realignment is threatening the substantial gains of the last 20 years.

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.

Acute decompensated cirrhosis (AD) refers to the development of ascites, encephalopathy, gastrointestinal haemorrhage, or any combination of these disorders in a patient with known or previously undiagnosed advanced chronic liver disease. It carries a significant mortality, particularly if associated with organ failure (acute on chronic liver failure (ACLF)). Admissions with AD have increased by 50% over the last decade, and liver-related deaths have increased by 64% in the last 20 years. UK-wide reports and audits, including by the National Confidential Enquiry into Patient Outcome and Death, have revealed unwarranted variation in care and outcomes for patients with AD. This article summarises the management of patients admitted with AD, including the British Society of Gastroenterology (BSG) / British Association for the Study of the Liver (BASL) / Society of Acute Medicine (SAM) decompensated cirrhosis care bundle, developed for completion in the first 6 h of admission to standardise care for these complex patients.