Clinical Medicine最新文献

Strongyloidiasis is a helminth infection where symptoms vary, and asymptomatic presentation is common. Chronic strongyloidiasis can cause a high mortality 'hyper-infection' in immunocompromised states. Understanding at risk populations and symptomology can guide screening and early treatment to reduce hyper-infection risk. A systematic review of studies describing patients in the UK with strongyloidiasis pooled a total of 1,308 patients. Weighted pooled prevalence (WPP) of asymptomatic cases was 27.7% (95% CI 17.1-39.5%, I² = 92%, p < 0.01). At-risk populations included migrants, returning travellers and armed forces personnel. The most common symptoms reported were abdominal pain (WPP 32.1% (95% CI 20.5-44.8%), I² = 93%, p < 0.01), rashes (WPP 38.4% (95% CI 13.1-67.7%), I² = 99%, p < 0.01) and diarrhoea (WPP 12.6% (95% CI 6.7-19.9%), I²=70%, p = 0.03). Symptomatology varied with cohort characteristics. Although asymptomatic presentation is common, patients may present with abdominal pain, diarrhoea or rashes. A low threshold for screening symptomatic individuals in at-risk groups is required.

Many patients with obstructive sleep apnoea (OSA) remain undiagnosed and thus untreated, and in part this relates to delay in diagnosis. Novel diagnostic strategies may improve access to diagnosis. In a multicentre, randomised study, we evaluated time to treatment decision in patients referred for suspected OSA, comparing a mandibular movement (MM) monitor to respiratory polygraphy, the most commonly used OSA detection method in the UK. Adults with high pre-test probability OSA were recruited from both northern Scotland and London. 40 participants (70 % male, mean±SD age 46.8 ± 12.9 years, BMI 36.9 ± 7.5 kg/m², ESS 14.9 ± 4.1) wore a MM monitor and respiratory polygraphy simultaneously overnight and were randomised (1:1) to receive their treatment decision based on results from either device. Compared to respiratory polygraphy, MM monitor reduced time to treatment decision by 6 days (median(IQR): 13.5 (7.0-21.5) vs. 19.5 (13.7-35.5) days, P = 0.017) and saved an estimated 29 min of staff time per patient.

Objectives: We aimed to assess the appropriateness of penicillin allergy (PenA) assessment conducted by clinical teams and to review the safety of subsequent exposure of these patients to penicillin.

Methods: Opportunistic, prospective observational study of usual clinical care, between 16 May 2023 and 14 August 2023, of inpatients with a PenA and requiring antibiotics, in a 750-bed hospital in England. To assess the appropriateness of management, PenA patients prescribed penicillins were grouped into risk categories using a validated antibiotic allergy assessment tool: eligible for de-label on history alone (direct de-label; DDL), eligible for direct oral challenge (DOC), high risk or unable to obtain history.

Results: Of the 123 patients admitted with a PenA (or sensitivity record) and exposed to a penicillin, data were collected for 50. Their PenA records were grouped follows: eligible for DDL 34 (68%), eligible for DOC 11 (22%), high risk 4 (8%) and unable to obtain history 1 (2%). In 14/50 (28%) patients there was no evidence of a current PenA assessment in the medical notes.

Conclusions: Using the allergy risk tool, most patients with PenA records were exposed to penicillin appropriately. However, patients meeting high-risk criteria were also exposed to penicillin when the tool excluded them. PenA assessment needs to be carried out with appropriate training and governance structures in place.

Same-day emergency care (SDEC) in unplanned and emergency care is an NHS England (NHSE) priority. Optimal use of these services requires rapid identification of suitable patients. NHSE suggests the use of one tool for this purpose. This systematic review compares studies that evaluate the performance of selection tools for SDEC pathways. Nine studies met the inclusion criteria. Three scores were evaluated: the Amb score (seven studies), Glasgow Admission Prediction Score (GAPS) (six studies) and Sydney Triage to Admission Risk Tool (START) (two studies). There was heterogeneity in the populations assessed, exclusion criteria used and definitions used for SDEC suitability, with proportions of patients deemed 'suitable' for SDEC ranging from 20 to 80%. Reported score sensitivity and specificity ranged between 18-99% and 10-89%. Score performance could not be compared due to heterogeneity between studies. No studies assessed clinical implementation. The current evidence to support the use of a specific tool for SDEC is limited and requires further evaluation.

The gap in excess mortality between patients with and without diabetes has not decreased over time. The aim of this study was to investigate the determinants of mortality after acute myocardial infarction (AMI) in patients with diabetes and without diabetes in a contemporary population. A retrospective analysis of a cohort of 266 patients with a diagnosis of AMI during 2022 was carried out. Patients living with diabetes had higher 1-year mortality, even after adjustment for covariates. Estimated glomerular filtration (eGFR) rate was independently associated with increased mortality in patients with diabetes. Plasma glucose was independently associated with peak troponin in patients both with and without diabetes. These data suggest that patients living with diabetes and with a low eGFR warrant more aggressive risk reduction and use of nephroprotective medications. Further studies are needed to assess whether early blood glucose control improves cardiovascular outcomes in all patients with AMI.

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.

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.

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.