Clinical Medicine最新文献

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.

Palliative care is the active holistic (physical, psychological, social and spiritual) care of people who experience health-related suffering due to severe illness and those close to them, aiming to improve their quality of life. There are three levels of palliative care: palliative care approach, generalist palliative care, and specialist palliative care. Traditionally associated with end-of-life care, this article highlights the evolution of specialist palliative care, now deemed to be applicable throughout the course of an illness. Terminologies surrounding 'palliative care' are also considered, especially the notable nomenclature debate between 'palliative care' and 'supportive care'. Specialist palliative care has evolved somewhat over time, and will need to continue to evolve to maintain its relevance.

Background: Cigarette smoking remains the commonest cause of chronic obstructive pulmonary disease (COPD) and respiratory bronchiolitis-associated interstitial lung disease (RB-ILD). Biomass combustion remains a high risk for causing respiratory disease.

Method: We present a case of a 41-year-old woman and never-smoker with worsening breathlessness. It was identified that she made fire pits burning sage and oils for spiritual work, but beyond this had no respiratory risk factors.

Results: Radiological evidence of RB-ILD was identified and a bronchoscopic lavage demonstrated the presence of striking green pigmented macrophages, presumed to be chlorophyll uptake.

Conclusions: Cessation of burning sage exposure has resulted in a positive outcome. This case highlights the need for an extensive occupational or exposure history in respiratory medicine and describes histological features of interstitial lung disease not previously identified.

Sedation is commonly used at the end of life; however, there are several practical and ethical considerations for its use. It is important to identify any treatable causes for agitation prior to initiating medication. The drug, dose and route of administration may vary according to the indication for treatment, and specialist advice or supervision may be required. There are a number of ethical and cultural considerations relevant to the use of palliative sedation, which must also be understood to ensure best practice in this area.

Study objective: To evaluate the influence of the perceived level of workplace support and its individual components in improving mental health and reducing burnout among healthcare professionals (HCPs).

Design: In a cohort of 400 HCPs followed up since July 2020, a follow-up survey was done online (August 2023) containing detailed questionnaires regarding workplace support and mental health.

Participants: 400 UK-based HCPs.

Main outcome measure(s): The level of individual workplace support components (perceived manager's concern for staff welfare, transparent communication, adequate staffing/safety, visible and approachable leadership, and collegial/peer support) were assessed using self-rating scales. Depression (PHQ-9), anxiety (GAD-7), insomnia (ISI), mental wellbeing (SWEMWBS) and burnout (emotional exhaustion, aMBI-EE; and depersonalisation, aMBI-DP) were assessed using validated tools.

Results: Compared with feeling unsupported, feeling supported was associated with a reduced risk of probable depression, insomnia, low wellbeing and burnout, and was associated with an increased perceived level of all individual support components. An increase in the perceived level of collegial/peer support was associated with reduced depression, anxiety, insomnia and burnout, and increased wellbeing scores (all p-values <0.01). An increase in the perceived level of managerial understanding of staff welfare was associated with reduced burnout (emotional exhaustion) among HCPs (p<0.05). There was also evidence that varying levels of visible and approachable leadership may impact on depression, anxiety and insomnia (p<0.05).

Conclusions: Adverse mental health and burnout among HCPs may be mitigated by good quality workplace support, specifically by fostering collegial/peer support among staff and ensuring that managers show genuine understanding for staff welfare and are visible and approachable in their leadership. These findings may guide the allocation of workplace support resources for HCPs.

The use of assisted reproductive technology (ART) has dramatically changed the landscape for treatment of infertility. Increasingly, healthcare practitioners of all specialisms are likely to encounter patients who have had ART, and therefore are expected to have knowledge of this area and counsel patients appropriately. There is, however, a lack of education about fertility techniques at both undergraduate and postgraduate level. Here we outline the main treatment options available to those undergoing ART, and the key considerations relevant to specialty physicians.

Advance care planning (ACP) is done in anticipation of something adverse happening and the likelihood of losing the capacity to be involved in future decision making. ACP encourages people to think about what might happen in serious illness scenarios and to consider their needs or wishes. As long-term conditions, multimorbidity, frailty and end-of-life care become more dominant health challenges, planning for future problems and giving patients and their carers the tools to self-manage becomes more imperative. ACP is part of this philosophy of care, anticipating and planning for future health and care needs. Increasingly, the utility of ACP seems to lie more in promoting conversations and particularly shining a light on the values that give people their identity. Patient relationships with family caregivers and health professionals, and a collective shared understanding, improve through the ACP process. Enabling people to be cared for in a way that preserves their identities and values for as long as possible seems to be more effective than focusing on documentary outputs.