Postgraduate Medical Journal最新文献

Introduction: To describe critical tasks and errors associated with intercostal chest drain insertion, in order to develop enhanced procedural guidelines for task performance and training.

Methods: Expert emergency medicine physicians participated in a three-phased study. First, hierarchical task analyses was used to identify tasks, sub-tasks, and the sequence of tasks. Second, systematic human error reduction and prediction approach was used to identify and classify the errors associated with each sub-task culminating in a probability, criticality, and detectability rating for each error. Third, failure modes, effects and criticality analysis technique was used to convert probability and criticality estimates to occurrence and severity scores. Criticality index score, a measure of the propensity for the error to cause harm or procedural failure for each error, was calculated and the top 20 errors most likely to cause harm were ranked.

Results: Thirteen tasks and 61 sub-tasks were identified and yielded 86 potential errors. Error classification included errors of action, checking, and selection. The error with the highest criticality score was 'identifying a point of entry lower than the fifth intercostal space'. The top four ranked errors all relate to the identification and correct marking of the location site for the intercostal drain within the safe triangle.

Conclusions: Tasks and sub-tasks associated with intercostal chest drain insertion was described and evaluated for criticality. The most critical task was the correct identification of a safe insertion point. Applications include development of procedural guidelines with tasks vulnerable to error highlighted and training interventions that promotes safe task performance.

Objective: To compare the speed of achieving painless uterine contractions in parturients undergoing epidural analgesia at different lumbar puncture levels.

Methods: This study is a randomized controlled trial at a tertiary A hospital with a history of over 80 years in Sichuan Province, China. Parturients aged 22-40 years old scheduled for vaginal delivery under epidural analgesia were recruited. Eligible patients were randomly allocated into lumbar 2-3 (L2-3) or lumbar 3-4 (L3-4) groups. Epidural analgesia was performed through the interspaces according to grouping. The primary outcome was the percentage of painless uterine contractions 15 min after the initiation of analgesia. The secondary outcomes included the percentage of painless status at 5 and 10 min, sensory block plane, motor block evaluation, adverse events of parturients, epidural analgesic consumption, Apgar score, and the parturients' evaluation of analgesia.

Results: Between April 2023 and August 2023, a total of 150 women were finally recruited, and 136 of them were analyzed (68 in each group). In comparison with the L3-4 groups, there was a significantly larger proportion of painless uterine contractions at 5, 10, and 15 min after analgesia initiation in the L2-3 group (20.6% vs. 7.4%, 52.9% vs. 26.5%, and 80.9% vs. 64.7%, P = .026, .002, and .034, respectively). Similarly, the pain scores were lower in the L2-3 group at 5, 10, and 15 min than that in the L3-4 group (5(4,7) vs. 6(5,7), 3(2,5) vs. 4(3,6), and 2(1,3) vs. 3(2,5), P = .006, .004, and .020, respectively). Furthermore, puncturing through the L2-3 interspace contributed to a higher evaluation of parturients to the analgesia procedure (9(8,9) vs. 8(8,9), P < .001). However, there was no significant difference in sensory block, motor block, or adverse events between the two groups.

Conclusion: Puncturing through the L2-3 interspace is associated with faster pain relief and a better experience for parturients. These findings present a superior option for anesthesiologists when conducting epidural labor analgesia. Key messages What is already known on this topic?  Epidural analgesia is an effective way to relieve labor pain. What this study adds?  Puncturing via lumbar 2-3 interspace induces more rapid onset of epidural analgesia. How this study might affect research, practice or policy?  Lumbar 2-3 interspace is a superior option in terms of the speed of pain relief and satisfaction of parturients when conducting epidural labor analgesia.

The term neurodiversity was coined in the 1990s to describe a diversity in thinking, learning, and processing the world around us, and is associated with strengths as well as challenges. Rates of diagnosis of neurodivergent conditions are rising rapidly amongst patients and healthcare professionals, largely due to a recent surge in awareness and understanding of neurodiverse conditions and more inclusive diagnostic criteria. Societal adaptation, however, has lagged, and likely explains some of the psychosocial comorbidities of neurodiversity, as individuals are forced to adapt their personality and how they display their emotions to fit societal norms. There remains a lack of awareness and understanding of neurodiversity amongst the healthcare professions. There is also very limited published literature on the challenges and strengths of this group in the clinical environment. Here, we use a case study, focusing on attention deficit hyperactivity disorder to explore the relationship between neurodiversity and work from the perspective of a neurodiverse health care professional. We challenge the notion that neurodiversity itself is a disability, but more likely a result of lack of societal awareness and adaption. We suggest accommodations and training in the clinical environment to raise awareness and support neurodiverse healthcare professionals in order that they flourish rather than struggle in the workplace.

Subspecialty consultations are becoming highly prevalent in hospital medicine, due to an ageing population with multimorbid conditions and increasingly complex care needs, as well as medicolegal fears that lead to widespread defensive medical practices. Although timely subspecialty consultations in the appropriate clinical context have been found to improve clinical outcomes, there remains a significant proportion of specialty referrals in hospital medicine which are inappropriate, excessive, or do not add value to patient care. In this article, we sought to provide an overview of the common problems pertaining to excessive quantity and suboptimal quality of inpatient subspecialty consultations made in real-world practice and highlight their implications for healthcare financing and patient care. In addition, we discuss the underlying contributing factors that predispose to inappropriate use of the specialist referral system. Finally, we offer a practical, multitiered approach to help rationalize subspecialty consultations, through (i) a systematic model ('WISE' template) for individual referral-making, (ii) development of standardized healthcare institutional referral guidelines with routine clinical audits for quality control, (iii) adopting an integrated generalist care model, and (iv) incorporating training on effective referral-making in medical education.

Defective telomerase function or telomere maintenance causes genomic instability. Alterations in telomere length and/or attrition are the primary features of rare diseases known as telomere biology disorders or telomeropathies. Recent advances in the molecular basis of these disorders and cutting-edge methods assessing telomere length have increased our understanding of this topic. Multiorgan manifestations and different phenotypes have been reported even in carriers within the same family. In this context, apart from dyskeratosis congenita, disorders formerly considered idiopathic (i.e. pulmonary fibrosis, liver cirrhosis) frequently correlate with underlying defective telomere maintenance mechanisms. Moreover, these patients are prone to developing specific cancer types and exhibit exceptional sensitivity and toxicity in standard chemotherapy regimens. The current review describes the diverse spectrum of clinical manifestations of telomere biology disorders in pediatric and adult patients, their correlation with pathogenic variants, and considerations during their management to increase awareness and improve a multidisciplinary approach.

Background: Immune inflammation is intricately associated with coronary artery disease (CAD) progression, necessitating the pursuit of more efficacious therapeutic strategies. This study aimed to uncover potential therapeutic targets for CAD and myocardial infarction (MI) by elucidating the causal connection between regulatory immune-related genes (RIRGs) and these disorders.

Methodology: We performed summary data-based Mendelian randomization analysis to assess the therapeutic targets linked to expression quantitative trait loci and methylation quantitative trait loci of RIRGs in relation to CAD and MI. Independent validation cohorts and datasets from coronary artery and left ventricular heart tissue were analyzed. To strengthen causal inference, colocalization analysis and PhenoScanner phenotype scans were employed.

Results: Utilizing multiomics integration, we pinpointed EIF2B2, FCHO1, and DDT as CAD risk genes. Notably, EIF2B2 and FCHO1 displayed significant associations with MI. High EIF2B2 expression, regulated by cg16144293, heightened CAD and MI risk at rs175438. In contrast, enhanced FCHO1 expression, modulated by cg18329931, reduced CAD and MI risk at rs13382133. DDT upregulation influenced by cg11060661 and cg09664220 was associated with decreased CAD risk at rs5760120. Colocalization analysis firmly established these relationships.

Conclusion: EIF2B2, FCHO1, and DDT represent risk loci for CAD progression within RIRGs. Our identification of these genes enhances understanding of CAD pathogenesis and directs future drug development efforts.

Many emotions are generated within a medical consultation. These feelings are often shared among the doctor, patient, and family. In this piece, these emotions are explored as I describe them deeply during my first encounter with a Huntington's disease patient, bringing the challenges of the situation, mistakes, and the learning that emerged. Understanding the possible sentiments and how to balance these emotions may be essential to prepare the neurologist in training for the challenges inherent in treating a patient with a rare disease.

Background: Obesity is a crucial risk factor for asthma. Observational studies have examined the association between abdominal obesity and asthma symptoms. This study aimed to investigate the causal relationship between visceral adipose tissue (VAT) and asthma and its potential as an independent indicator.

Methods: This study utilized data from the National Health and Nutrition Examination Survey spanning 2011-8. Multivariable logistic regression and stratified variable selection were employed to identify associations between asthma and VAT. Moreover, a two-sample Mendelian randomization analysis, using 221 genetic variants as instrumental variables, was conducted to assess this relationship further.

Results: Our findings indicated that individuals with higher VAT levels were more likely to develop asthma. Visceral obesity remained a significant risk factor for asthma after adjusting for demographic characteristics. Genetic predictions suggest a positive association between VAT and an elevated risk of asthma (odds ratio [OR] = 1.393, 95% confidence interval [CI]: 1.266-1.534, and P = 1.43E-11). No significant polymorphisms were detected using the Mendelian randomization-Egger intercept test.

Conclusions: This study presents potential evidence supporting the causal role of VAT in asthma development. Furthermore, the findings from the Mendelian randomization analysis further reinforce the relationship between VAT and asthma risk.