Clinical Medicine最新文献

Disease-modifying anti-rheumatic drugs (DMARDs) have revolutionised the treatment landscape in rheumatology, reducing both disease severity and the risk of systemic comorbidities. These immunomodulatory drugs have been repurposed for use in other chronic inflammatory diseases, conferring further advantages. However, DMARDs can be associated with adverse events that have implications for the management of common symptoms and conditions that present to medical services at the 'front door'.

The management of pituitary disorders in pregnancy presents a unique challenge for maternal medicine specialists and endocrinologists. Advances in assisted reproductive technologies (ART) mean that women with hypopituitarism are increasingly able to conceive. The pituitary undergoes significant physiological changes during pregnancy. Pituitary hormone replacement regimens must therefore be adjusted throughout pregnancy in an attempt to mimic these changes. Close clinical and biochemical follow-up and collaboration across specialties is essential to ensure optimal maternal and fetal outcomes. Although many women with hypopituitarism will have a normal pregnancy, rates of miscarriage, labour induction and caesarean sections are higher than the general population. Most women with hypopituitarism are diagnosed prior to pregnancy; however, some pituitary disorders including lymphocytic hypophysitis, Sheehan's syndrome and pituitary apoplexy have a predilection to arise during pregnancy or the postpartum period. Prompt recognition of these disorders is essential to prevent potentially fatal complications and optimise maternal and fetal wellbeing.

Immune-mediated inflammatory diseases (IMIDs) are a group of common clinically diverse conditions that are characterised by systemic inflammation. They often pose medical challenges due to their multi-organ involvement, chronicity, associated comorbidities and poor impact on quality of life for patients. The management for IMIDs has changed profoundly over the past 20 years, with the paradigm of treatment shifting away from broad immunosuppression towards pathway-specific targeted treatment. This editorial will focus on three immune mediated rheumatic diseases that physicians may encounter in their clinical practice; rheumatoid arthritis (RA), idiopathic inflammatory myositis (IIM) and anti-neutrophil cytoplasm antibodies (ANCA)-associated vasculitis (AAV). This editorial will provide a concise overview of the current targeted treatment landscape of these three conditions.

The prevalence of diabetes mellitus (DM) during pregnancy is rising globally, yet data on gestational diabetes mellitus (GDM) in South Africa remain limited. This study retrospectively analysed glycaemic characteristics and outcomes in 298 women with pre-gestational DM and hyperglycaemia first detected in pregnancy (HFDP) between August 2019 and January 2021. Hyperglycaemic disorders were attributed to GDM (39.6%, n = 118), followed by type 2 diabetes (T2DM) (29.2%, n = 87), overt DM (22.1%, n = 66) and type 1 diabetes (T1DM) (9.1%, n=27). Significant risk factors for GDM included family history, obesity, poor obstetric history, and a previous history of macrosomia in pregnancy. Glycated haemoglobin (HbA1c) levels at booking were highest in women with pre-gestational DM (8.8% in T1DM and 7.8% in T2DM). A combination of HbA1c ≥ 5.75% and fasting plasma glucose (FPG) of 5.1-6.9 mmol/L was the most accurate method for diagnosing GDM, with an area under the curve (AUC) of 0.93. Postpartum follow-up using an oral glucose tolerance test (OGTT) revealed that 21% of women with GDM developed DM, while 53% had an impaired glucose tolerance (IGT). However, only 48% of those with GDM were followed up postpartum, highlighting the significant challenge of loss to follow-up. These findings emphasise the growing prevalence of HFDP and the elevated risk of postpartum DM, highlighting the need for improved follow-up care to mitigate long-term complications. Additionally, the combination of FPG and HbA1c ≥ 5.75% shows promise for enhancing GDM diagnosis and screening protocols, particularly in developing countries. Further research is needed to validate these findings and assess their broader applicability.

Background: There is an established link between air pollution and chronic disease. In this study, we measure the impact and health burden of fine particulate matter (PM_2.5) in chronic disease in the United States (USA), specifically type 2 diabetes mellitus (T2DM), chronic obstructive pulmonary disease (COPD), ischaemic heart disease (IHD) and stroke.

Methods: Data on the global burden of chronic disease attributable to air pollution were obtained from Global Burden of Diseases (GBD) 2021 study. The number of deaths and disability-adjusted life years (DALYs) attributable to air pollution from 1990 to 2021 were extracted and analysed by different US locations and years.

Results: The death rates due to chronic diseases attributable to PM_2.5 in the USA have decreased significantly. In 2021, death rates were lowest for T2DM (1.307), followed by stroke (2.004), COPD (2.119) and IHD (5.865). Between 1990 and 2021, death rates declined by 36% for T2DM, 30% for COPD, 70% for IHD and 61% for stroke. DALY rates in 2021 were lowest for stroke (52.389), followed by COPD (54.147), T2DM (73.32) and IHD (119.471), with reductions of 16.4%, 39.6%, 70.3% and 58.9%, respectively, since 1990. High-sociodemographic index (SDI; a measure of social and economic development) states saw greater improvements, with average annual percentage change (AAPCs) of -5.2% for IHD and -2.68% for COPD, compared to -4.4% and -1.35% in low-SDI states. Higher-income states also showed faster declines, such as an AAPC of COPD death rates of -2.51% versus -1.21% in low-income states.

Discussion: The results highlight a decreasing trend in death rates and DALYs and identify varying locations that remain at high risk of health burden from PM_2.5-associated chronic disease. There is a continued need for addressing air pollution control and policy revisions targeted to patient subpopulations in the USA where the burden of PM_2.5 can still be detrimental.

Background: Smell disturbances, memory and mood changes are frequently reported as symptoms of long COVID that can be debilitating and long-lasting, having a detrimental impact on a patient's quality of life and possibly contributing to depression and a decline in cognitive abilities.

Study objective: This study aims to investigate long-term post-COVID cognitive and olfactory disturbances among the COVID-19 convalescent adult Armenian population aged between 18 and 65 years. The assessment extends to the differentiation of various olfactory distortions and association between various olfactory and cognitive variables, grouped by participants' olfactory hallucination status.

Study design: Explanatory sequential mixed-methods design was employed. Through three follow-up visits, the quantitative phase evaluated olfactory and cognitive abnormalities following COVID-19, comparing those with and without olfactory hallucinations. Through in-depth interviews, the qualitative phase investigated how participants perceived these symptoms and their impact on their quality of life.

Study participants: The quantitative study participants were those who self-reported subjective disturbances in the olfactory perception 14 days following a COVID-19 diagnosis, as confirmed by a positive PCR test at the time of diagnosis. The qualitative study participants were those who self-reported persistent olfactory disturbances post-visit 3.

Results: The study found that olfactory hallucinations lead to more pronounced depression compared with non-hallucinogenic types of olfactory disturbances. It was determined that a significant predictor of parosmia is persistent anosmia up to 4 months following COVID-19 infection.

Conclusion: The long-term olfactory disturbances post-COVID-19 infection have a better prognosis among participants without olfactory hallucination compared to participants with olfactory hallucination.

Systemic lupus erythematosus (SLE) is a lifelong, complex, multi-system, autoimmune condition which can occur at any age, most commonly in female adults in their reproductive years. Diagnosis is often delayed, with reported time from symptom onset to diagnosis as long as 6 years. Delayed diagnosis can result in irreversible organ damage, acute hospital admission, poor health-related outcomes and increased risk of mortality. SLE is a clinical diagnosis that requires a combination of clinical and immunological features attributable to lupus. Classification criteria have undergone several revisions and can be used to guide diagnosis. This article will review challenges in making a timely diagnosis of SLE, including heterogeneity of clinical and immunological features, disease mimickers, problems with diagnostic tests, and difficulties faced by general physicians and rheumatologists, with the aim to update knowledge among general physicians on clinical presentations and when to refer suspected patients to specialists.

Sodium-glucose transport-2 (SGLT2) inhibitors are commonly prescribed for the management of type 2 diabetes mellitus, chronic kidney disease and heart failure. However, their continuation in the perioperative setting in people with diabetes can precipitate euglycaemic diabetic ketoacidosis (EDKA), a potentially life-threatening complication. This multi-cycle audit evaluated adherence to perioperative guidelines regarding preoperative cessation and postoperative re-initiation of SGLT2 inhibitors. Electronic health records of consecutive surgical patients with type 2 diabetes were reviewed over a 6-month period. Two cases of EDKA were identified. Targeted interventions - including staff education and dissemination of guidance - were implemented, followed by re-audit over a 4-month period. Documentation and perioperative SGLT2 inhibitor cessation improved significantly post-intervention; however, postoperative ketone monitoring remained suboptimal, and one further case of EDKA was identified. Since then, capillary blood ketone monitoring has been introduced in clinical areas. These findings add to the body of evidence on the perioperative use of SGLT2 inhibitors.

Set in a district general hospital, this case series explores two individuals who developed a rare multisystemic syndrome:; polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin abnormalities (POEMS). Diagnostic journey, trajectory of disease and outcomes are compared. Both patients presented to healthcare numerous times and saw multiple specialists for symptoms resulting predominantly from volume overload and neuropathy, prior to being admitted with atypical ischaemic stroke. During their admission, diagnosis was made after atypical intracranial arterial stenoses, sensory neuropathy not in keeping with their stroke, plasmacytoma detection and confirmatory raised vascular endothelial growth factor (VEGF) levels. POEMS is highly treatment responsive, survival rate improving with earlier diagnosis. Both patients were transferred to specialist centres for chemotherapy. Unfortunately, patient outcomes significantly differ, one having favourable recovery, while the other experiencing treatment-resistance disease requiring local repatriation for withdrawal of care. We identify challenges faced by both patients and the medical team, and discuss the importance of the general physician within the world of specialist medicine, in order to provide holistic, comprehensive patient care.