Clinical Medicine最新文献

All of us will one day die. For most of us, death will be anticipated, usually following a period of ill health. The opportunity to anticipate and manage clinical conditions associated with the agonal process is an essential part of advance care planning. Guidelines exist for the palliation of most symptomatic events at the end of life, although many recommendations are based on low-quality evidence or consensus. Furthermore, when potentially practice-changing data emerge, there is an inevitable lag time before clinical practice changes. In this paper, we shall discuss the management of three challenging scenarios faced by teams looking after patients at the end of life: delirium, terminal haemorrhage and noisy upper airway secretions. We aim to critically evaluate the utility of current evidence, pharmacological and non-pharmacological, and how it translates into clinical practice.

Background: This study aims to evaluate the association between maternal hepatic steatosis index (HSI) in the first trimester and adverse perinatal outcomes.

Methods: A prospective birth cohort study was conducted from 19 February 2018 to 31 December 2022 in China. Logistic regression models and restricted cubic splines were used to estimate the associations of maternal HSI in early pregnancy and the risk of perinatal outcomes. Subgroup analyses stratified by maternal age and gravidity were carried out.

Results: A total of 42,589 participants were included in this study. The overall prevalence of caesarean delivery, preterm birth, large-for-gestational age (LGA), shoulder dystocia and low Apgar scores were 39.17%, 5.18%, 9.45%, 0.92% and 0.77%, respectively. With the increase of HSI quartiles, the incidence of caesarean delivery, preterm birth, large-for-gestational age (LGA) and shoulder dystocia significantly increased (P < 0.0001). The highest quartile of HSI was associated with the highest risk of caesarean delivery (odds ratio (OR) 1.777, 95% CI 1.674-1.886), preterm birth (OR 1.323, 95% CI 1.160-1.510), LGA (OR 2.743, 95% CI 2.468-3.049) and shoulder dystocia (OR 1.487, 95% CI 1.094-2.021). The associations between HSI and adverse perinatal outcomes showed non-linear relationships except for shoulder dystocia (P < 0.0001 for all, P = 0.4792 for non-linearity). Subgroup analyses revealed that the associations between HSI and the risks of LGA and caesarean delivery were significantly stronger in younger and first-time pregnant women.

Conclusion: Elevated maternal HSI in early pregnancy was positively associated with the risk of adverse perinatal outcomes.

Pregnancy is associated with a wide range of cutaneous changes. Some are physiological and triggered by normal hormonal fluctuations during pregnancy. There are also a small number of pathological pruritic eruptions that exclusively occur during pregnancy, known as pregnancy-specific dermatoses (PSDs). In patients presenting with a PSD, features often include severe pruritus and characteristic inflammatory skin changes differing in onset, morphology and configuration. This article gives an overview of benign dermatological changes during pregnancy and the most important presentations of PSDs in order of prevalence: atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis and pustular psoriasis of pregnancy. Importantly, we outline how a resident physician can identify these disorders, how to initiate management and when a specialty referral for further investigations and monitoring of the mother and unborn fetus is warranted.

The emergent field of interventional bronchoscopy provides an alternative approach for the diagnosis and management of a range of respiratory conditions. Within malignant disease, robotic navigational bronchoscopy provides a stable platform to sample small and difficult to reach pulmonary nodules, while malignant central airway obstruction can be managed through transcopic stent insertion. A range of therapeutic modalities have been developed for benign disease, which provide alternatives to standard therapy, particularly in the context of endobronchial valves for chronic obstructive pulmonary disease, and bronchial thermoplasty for asthma, while transbronchial cryoexcision lung biopsy offers a non-surgical option for undiagnosed interstitial lung disease. With a rich pipeline of technology being developed through robust clinical trial processes, the field of interventional bronchoscopy will continue to grow to become an invaluable asset, not only to the field of respiratory medicine, but to the general physician.

Occupational exposures are a common and preventable cause of lung disease. About one in six cases of chronic obstructive pulmonary disease (COPD) and asthma worldwide are related to work. Early recognition of occupational lung disease improves outcomes. Doctors should ask about work history in patients with respiratory symptoms. This educational review article briefly outlines key clinical features, relevant to the general physician, of common occupational lung diseases seen in the UK. These conditions include work-related asthma, pneumoconioses, hypersensitivity pneumonitis and COPD. Referral to a specialist is recommended when an occupational cause is suspected. Most occupational lung diseases are preventable with adequate workplace safety measures and early medical attention.

Pneumothorax is defined as air in the pleural space and is characterised by chest pain and breathlessness. It is commonly divided into spontaneous and non-spontaneous subtypes based on the underlying mechanism. Chest X-ray is the most common investigation to diagnose and monitor pneumothorax, but CT-chest is being increasingly used to aid decision making in complex cases and to investigate an underlying lung disease. There should be a low threshold to investigate for an underlying familial or catamenial cause in suspected cases. Treatment for pneumothorax is based on clinical condition and symptoms of the patient rather than the size of pneumothorax. Conservative care can be offered to minimally symptomatic primary spontaneous pneumothorax patients, while needle aspiration, ambulatory Heimlich valve device and chest drain remain the interventional treatment options. Chest drain is a common treatment for patients with secondary spontaneous pneumothorax due to poor lung reserve. Recurrence after spontaneous pneumothorax is common and smoking cessation reduces the risk of future recurrence in active smokers. Surgical treatment with pleurodesis ± bullectomy should be considered for treatment of suitable patients with persistent air leak and for pneumothorax recurrence prevention in high-risk populations.

The GMC's Medical Licensing Assessment (MLA) marks a pivotal moment in UK medical education: the 2025 graduating cohort will be the first required to pass this national exam before entering clinical practice. The accompanying MLA 'Content Map' lists 217 clinical presentations and 315 conditions - across 25 areas of clinical practice that students need to know by the end of the programmes. While some medical educators may simply use this list to confirm whether timetabled teaching covers the material required, others may use the list a driver for curriculum change and transformation. In the case of the latter, meaningful opportunity now exists for collaborative redesign of undergraduate programmes, comprising everything from removing terms such as 'pre-clinical' and 'clinical' through to promoting more integrated approaches to delivering medical education and developing clinical reasoning using more authentic, applied workplace-based learning activities.

Sarcoidosis is a complex disease of unknown origin, primarily affecting the lungs but capable of involving almost any organ. Diagnosis is challenging due to the lack of specific markers and requires assessment of clinical features, careful imaging, exclusion of other conditions and, ideally, a tissue biopsy demonstrating non-necrotising granulomas. Over 90% of patients have pulmonary involvement, presenting with symptoms like dry cough and breathlessness, along with systemic signs such as fever and weight loss. Extrapulmonary manifestations occur in about 30% of cases and can affect any organ, including the heart, nervous system and eyes. Management involves a multidisciplinary approach with some patients requiring immunosuppressive and antifibrotic therapies. Despite generally good outcomes, sarcoidosis can lead to significant morbidity and mortality, particularly from pulmonary and cardiac complications. Emerging treatments like infliximab and nintedanib offer hope for refractory cases, although they carry risks of serious infections and other side effects.