Clinical Medicine最新文献

The initiation, continuance or discontinuance of clinically assisted hydration and nutrition are some of the most challenging decisions in patients near the end of life. This article reviews the limited evidence to support or otherwise these medical treatments, and provides an overview of relevant clinical practice guidance. Essentially, decisions need to be individualised, and importantly regularly reviewed to ensure that the objectives of treatment are being achieved.

Women with cystic fibrosis (wwCF) are increasingly undertaking pregnancy. This study assessed the current state of relationships, fertility, pregnancy and parenthood in a total cohort of 217 wwCF. Overall, 64% of wwCF were in long-term heterosexual relationships, 32% were single and 4% were in same-sex relationships; 64 wwCF had 111 children; 97 (87.4%) were conceived naturally and 10 (9%) by assisted reproduction. One woman had two children by surrogacy, one couple adopted a child and six wwCF had a role as a step-parent. Of the 217 wwCF, 31 (14%) died at a mean age of 41.4 years; they had 18 children, and eight of these children (44%) were younger than 18 years old when their mother died. There was a marked increase in pregnancies associated with the introduction of CF modulator medications, from three in 2020 to 16 in 2023. There were 50 pregnancies between 2020 and 2024; 17 (34%) were not planned (five were terminated); and 15 (30%) partners did not have CF genetic tests pre-conception. There were eight miscarriages. Exacerbations of lung disease occurred in 11 (31%) completed pregnancies, gestational diabetes in 12 (34%), one gastrointestinal bleeding, and one pre-eclampsia. Delivery was by caesarean section in 14 pregnancies (40%), and four (11%) births were premature (<37 weeks gestation). Although outcomes are generally good, pre-conception planning is suboptimal, pregnancy is associated with increased complications and parenthood raises complex issues regarding prognosis. CF teams should have close links with maternal medicine services to meet the specific needs of wwCF.

Background: Chronic liver disease (CLD) is associated with worse outcomes in many medical conditions, but its impact on patients with spontaneous intracranial haemorrhage (ICH) has not been fully explored. This study aims to evaluate the influence of CLD on in-hospital outcomes of patients with a spontaneous ICH.

Methods: Data from the Nationwide Readmissions Database (NRD) between 2016 and 2020 were retrospectively reviewed. Patients ≥18 years old admitted for the first time with a spontaneous ICH were included. Study outcomes included in-hospital mortality, length of stay (LOS), major complications and 90-day readmission rate. Patients with and without CLD were matched using 1:4 propensity score matching (PSM). Univariate and multivariable logistic and linear regression analyses were performed to determine the associations between CLD and outcomes of interest.

Results: After applying PSM, 21,345 patients were included in the analysis, of whom 4,269 had CLD. After adjustment, compared to patients without CLD, those with CLD had significantly higher in-hospital mortality (adjusted odds ratio (aOR) = 1.23, 95% confidence interval (CI): 1.13-1.34, p < 0.001), a longer LOS (aOR = 1.26, 95% CI: 1.12-1.39, p < 0.001), higher rates of major complications (aOR = 1.76, 95% CI: 1.62-1.91, p < 0.001) and increased 90-day readmission rates (aOR = 1.20, 95% CI: 1.09-1.31, p < 0.001)​.

Conclusions: CLD is independently associated with higher mortality, more complications, longer LOS and higher readmission rates in patients admitted for spontaneous ICH. These findings underscore the need for specialised care strategies for patients with an ICH and underlying CLD.

Background: Alzheimer's disease (AD) remains a major challenge due to limited effective therapies. Moreover, direct comparisons between newly developed and symptomatic drugs are lacking. This network meta-analysis aimed to compare the efficacy and safety of immunotherapies for AD.

Methods: A systematic search of PubMed, Embase, the Cochrane Library and ClinicalTrials.gov was conducted for randomised controlled trials (RCTs) up to 29 June 2024. Eligible studies included adults with AD receiving immunotherapy versus placebo or symptomatic treatment.

Results: Fifty-nine RCTs were included. Donanemab and lecanemab ranked among the most effective treatments for improving cognitive function (Clinical Dementia Rating Scale - Sum of Boxes P-scores: 0.88 and 0.77) and daily activities (Alzheimer's Disease Cooperative Study - Activities of Daily Living P-scores: 0.85 and 0.90), based on network meta-analysis findings.

Conclusions: Anti-Aβ monoclonal antibodies, particularly donanemab and lecanemab, demonstrated superior efficacy over other immunotherapies in slowing cognitive deterioration, supporting their role in AD management.

Prospero registration number: CRD42023461680.

Managing cancer-related pain remains a major clinical challenge, particularly in the context of increasing concerns around opioid use. The World Health Organization (WHO)'s analgesic ladder, a widely used framework for cancer pain management, is being re-evaluated - especially the second step involving weak opioids such as codeine and tramadol. Evidence suggests that these offer limited benefit and more side effects compared to initiating treatment with strong opioids. As cancer care advances, more patients live longer with chronic pain, requiring a tailored, multimodal approach. Meanwhile, the global opioid crisis has led to heightened regulatory scrutiny, making prescribers more cautious and potentially contributing to the under-treatment of pain. Long-term opioid use is also associated with risks including cognitive impairment, opioid-induced hyperalgesia and endocrine dysfunction. This review examines the ongoing relevance and limitations of the WHO ladder, highlights the challenges of opioid toxicity, and advocates for a personalised, multidisciplinary strategy to deliver safe, effective and compassionate cancer pain relief.

It is imperative for clinicians to understand the common adverse effects of opioid therapy and ensure patients are properly counselled on them prior to opioid initiation. Predictable adverse effects are wide ranging, and include bowel dysfunction, nausea, sedation, endocrinopathy and pruritis. Many adverse effects (with the notable exception of constipation) improve with time; however, patients should undergo regular re-assessment to identify new or evolving symptoms. Opioid rotation can also be a useful therapeutic tool to mitigate intolerable opioid adverse effects. This article aims to provide a succinct review of important adverse effects and effective management techniques to enhance patient outcomes and quality of life.

Gout is the commonest form of inflammatory arthritis. Flares are the commonest presentation of gout. Typically, gout flares present as acute monoarthritis, and most often affect the first metatarsophalangeal joint ('podagra'). Other joints in the lower limbs are affected more often than those in the upper limbs. Joint aspiration followed by examination of the synovial fluid using a polarised light microscope is the gold standard for a definite diagnosis of gout. Gout may be diagnosed without recourse to joint aspiration if there is podagra, elevated serum urate and no suspicion of infection. Ultrasonography and dual energy computed tomography may be used to diagnose gout if joint aspiration is unsuccessful or not feasible. Oral colchicine, NSAIDs and glucocorticoids have similar efficacy for controlling gout flare with differing adverse effect profiles. Consequently, the drug choice depends on comorbidities and patient preference.

Pulmonary embolism (PE) is often regarded as an acute disorder, yet emerging evidence underscores its chronic trajectory. Many survivors endure long-term complications, including recurrent thrombosis, persistent dyspnoea and psychosocial challenges. These sequelae impair functional capacity and quality of life long after the initial event. To address these issues, we suggest that clinicians should adopt an integrated, multidisciplinary model that includes risk stratification for recurrence, structured follow-up, exercise rehabilitation, and support for psychological challenges. Recognising the potential chronic sequalae of PE ultimately fosters comprehensive care aimed at reducing morbidity and improving long-term outcomes for survivors.

Palliative care is essential for people with an advanced life-limiting illness. Most palliative care is delivered by healthcare professionals who do not specialise in palliative care ('non-specialists'). Multidisciplinary specialist palliative care services manage more complex problems, providing more comprehensive support when needed. Both 'non-specialist' and specialist palliative care improve patient and family outcomes and reduce formal healthcare costs. However, there are inconsistencies in the delivery of, and access to, 'non-specialist' and specialist palliative care. These inconsistencies and inequities lead to unrecognised and unmet palliative care needs. There is also inconsistent referral to specialist palliative care services. Unless there are greater resources and training, these issues will be exacerbated by an increasing need for palliative care with changing population demographics.