Medicine (Abingdon, England : UK ed.)最新文献

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Management of pre-gestational diabetes in pregnancy 妊娠期糖尿病的管理

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-10-01 DOI: 10.1016/j.mpmed.2024.07.007

Pre-gestational diabetes – type 1 and type 2 diabetes mellitus – affects 1.7% of all pregnancies in the UK, and 1.3% of all pregnancies worldwide. In the UK there are now more pregnancies in women with type 2 than type 1 diabetes mellitus. Pre-gestational diabetes is associated with increased maternal and fetal risk including congenital abnormalities, stillbirth and pre-eclampsia; diabetic ketoacidosis also affects >1% of pregnancies. There are three targets for pre-pregnancy to reduce complications: glycated haemoglobin <48 mmol/mol (6.5%); folic acid 5 mg for at least 1 month before pregnancy; and avoidance of all teratogenic drugs. In pregnancy, tight glycaemic control is recommended, with a target blood glucose range of 3.5–7.8 mmol/litre. Increased doses of insulin are required through the course of pregnancy because of increasing insulin resistance. Childbirth is generally recommended in all those with pre-gestational diabetes between 37 and 38⁺⁶ weeks because of the risk of stillbirth and other complications. Continuous glucose monitoring and hybrid closed-loop insulin delivery systems have been shown to improve pregnancy outcomes in type 1 diabetes.

妊娠前期糖尿病--1 型和 2 型糖尿病--影响着英国 1.7% 的孕妇和全球 1.3% 的孕妇。目前，在英国，2 型糖尿病孕妇比 1 型糖尿病孕妇多。妊娠前期糖尿病会增加母体和胎儿的风险，包括先天性畸形、死胎和先兆子痫；糖尿病酮症酸中毒也会影响 1%的孕妇。为减少并发症，孕前有三个目标：糖化血红蛋白 48 毫摩尔/摩尔（6.5%）；孕前至少 1 个月服用 5 毫克叶酸；避免服用所有致畸药物。在怀孕期间，建议严格控制血糖，目标血糖范围为 3.5-7.8 毫摩尔/升。由于胰岛素抵抗的增加，妊娠期间需要增加胰岛素的剂量。由于存在死胎和其他并发症的风险，一般建议所有妊娠 37 至 38+6 周的妊娠前期糖尿病患者分娩。连续血糖监测和混合闭环胰岛素输送系统已被证明可改善 1 型糖尿病患者的妊娠结局。

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Perinatal mental health 围产期心理健康

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-10-01 DOI: 10.1016/j.mpmed.2024.07.009

Pregnancy and the postpartum period are times of elevated risk for mental disorders, which are common and affect up to 20% of expectant and new mothers. Perinatal mental disorders are already the leading complications in the perinatal period, and evidence suggests their prevalence is increasing. Nevertheless, they remain underdiagnosed and undertreated, which is particularly concerning as they are associated with adverse maternal and infant outcomes. Perinatal psychiatry includes conditions that occur outside the perinatal period (e.g. anxiety, depression) and illnesses such as postpartum psychosis. Postpartum depression and psychosis significantly increase the risk of suicide, a leading cause of maternal mortality. Management of perinatal mental illness needs special consideration because of the impact on both the women and their babies. Use of psychotropic medications in pregnancy and breastfeeding requires risk–benefit analysis and careful discussion with specialist multidisciplinary teams and patients. Women tend to be particularly cautious of the potential risks that medication poses to the baby, and less aware of the risks to both mother and infant of untreated mental illness. Screening for mental illness can lead to timely diagnosis, treatment and, if required, specialist perinatal care and admission to a mother and baby unit, which have recently been expanded across the UK.

孕期和产后是精神障碍的高发期，精神障碍很常见，多达 20% 的准妈妈和新妈妈会受到影响。围产期精神障碍已经成为围产期的主要并发症，而且有证据表明其发病率正在上升。然而，围产期精神障碍的诊断和治疗仍然不足，这一点尤其令人担忧，因为围产期精神障碍与孕产妇和婴儿的不良结局息息相关。围产期精神病包括发生在围产期外的疾病（如焦虑症、抑郁症）和产后精神病等疾病。产后抑郁症和精神病会大大增加自杀的风险，而自杀是孕产妇死亡的主要原因。围产期精神疾病的管理需要特别考虑，因为这对产妇和婴儿都有影响。在孕期和哺乳期使用精神药物需要进行风险效益分析，并与多学科专家团队和患者进行仔细讨论。妇女往往对药物给婴儿带来的潜在风险特别谨慎，而对未经治疗的精神疾病给母亲和婴儿带来的风险则认识不足。精神疾病筛查可以帮助我们及时诊断和治疗精神疾病，并在必要时提供专业的围产期护理和入住母婴病房。

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Medical consultations on the labour ward: assessment and management of common medical presentations 产房医疗咨询：常见病症的评估和管理

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-10-01 DOI: 10.1016/j.mpmed.2024.07.010

Pregnancy and the postpartum period are a time of significant physiological adaptations that can impact on the presentation, assessment and diagnosis of common medical problems. Physicians can have limited postgraduate obstetric experience and yet be called upon to assess a pregnant woman in the context of new or pre-existing medical disease on the labour ward. This article reviews the evaluation and management of breathlessness, chest pain, palpitations, seizures, headache, acute kidney injury and sepsis. Through comprehensive assessment that is cognisant of normal pregnancy physiology, and by using the excellent resources now available from specialist organizations, physicians can offer a unique and valuable perspective for the multidisciplinary care of pregnant individuals.

妊娠期和产褥期是生理发生重大变化的时期，会对常见医疗问题的表现、评估和诊断产生影响。医生的产科研究生经验可能很有限，但却需要在产房对孕妇新发或原有疾病进行评估。本文回顾了呼吸困难、胸痛、心悸、癫痫发作、头痛、急性肾损伤和败血症的评估和处理。通过对正常妊娠生理的全面评估，并利用专业机构提供的优质资源，医生可以为孕妇的多学科护理提供独特而有价值的视角。

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Recreational nitrous oxide use and its clinical implications 娱乐性使用一氧化二氮及其临床影响

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-10-01 DOI: 10.1016/j.mpmed.2024.07.012

Nitrous oxide, a gas used in healthcare as an analgesic and anaesthetic and in the catering industry as a whipped cream aerosol propellant, has been misused since its discovery in the 18th century. It is commonly inhaled from balloons filled from 8 g whipped cream dispensers (‘whippets’), or more recently from larger 600 g to 2 g canisters. Acute complications include pneumothorax, hypoxia and frostbite from contact of the nitrous oxide canister with the skin or mucous membranes. Chronic use has the potential to cause nitrous oxide-induced neuropathy from sub-acute combined degeneration of the cord relating to functional vitamin B₁₂ deficiency; methylmalonic acid and homocysteine are biomarkers of nitrous oxide neuropathy. Other chronic effects include neuropsychiatric symptoms, anaemia, toxic leucoencephalopathy, rashes and an increased risk of thrombosis. Management of nitrous oxide neuropathy and other chronic complications consists of educating individuals on the importance of stopping nitrous oxide use, together with treatment with intramuscular vitamin B₁₂.

一氧化二氮是一种气体，在医疗领域用作镇痛剂和麻醉剂，在餐饮业用作鲜奶油气雾推进剂，自 18 世纪被发现以来一直被滥用。人们通常从 8 克装鲜奶油分配器（"Whippets"）或最近从 600 克至 2 克的大型罐装气球中吸入这种气体。急性并发症包括气胸、缺氧以及一氧化二氮罐与皮肤或粘膜接触导致的冻伤。长期使用有可能导致一氧化二氮诱发神经病变，这是因为功能性维生素 B12 缺乏引起的亚急性脊髓联合变性；甲基丙二酸和同型半胱氨酸是一氧化二氮神经病变的生物标志物。其他慢性影响包括神经精神症状、贫血、中毒性脑白质病、皮疹和血栓风险增加。对一氧化二氮神经病变和其他慢性并发症的治疗包括教育患者停止使用一氧化二氮的重要性，以及肌肉注射维生素 B12。

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Hypertension in pregnancy and pre-eclampsia 妊娠高血压和先兆子痫

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-10-01 DOI: 10.1016/j.mpmed.2024.07.011

Hypertension affects 8–10% of pregnancies and is the most common medical disorder in pregnancy. Despite continuing research and guideline development, maternal mortality from hypertensive diseases in pregnancy has increased in the last 6 years. It is vital that physicians are aware of the signs and symptoms, along with differing maternal treatment thresholds, of hypertension in pregnancy to ensure expeditious identification and treatment. New-onset hypertension developing at any stage of pregnancy requires a full history, examination and investigations to delineate an underlying cause and assess for target organ damage and the presence of pre-eclampsia to assign risk. Developing a hypertensive disorder in pregnancy increases a woman's life-long cardiometabolic risk; using this opportunity to inform and improve cardiovascular risk factors helps to prevent life-long health implications.

高血压影响着 8-10% 的妊娠，是妊娠期最常见的疾病。尽管不断进行研究和制定指南，但在过去 6 年中，妊娠期高血压疾病导致的孕产妇死亡率仍在上升。医生必须了解妊娠期高血压的体征和症状，以及孕产妇不同的治疗阈值，以确保快速识别和治疗。在妊娠的任何阶段出现新发高血压，都需要进行全面的病史、检查和化验，以确定潜在的病因，评估靶器官是否受损，以及是否存在先兆子痫以确定风险。妊娠期高血压疾病会增加妇女终生的心血管代谢风险；利用这一机会了解并改善心血管风险因素，有助于预防对终生健康的影响。

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Editorial: Medical problems in pregnancy 社论：孕期医疗问题

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-10-01 DOI: 10.1016/j.mpmed.2024.07.006

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Self-assessment/CPD answers 自我评估/继续教育答案

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-10-01 DOI: 10.1016/j.mpmed.2024.07.013

引用次数: 0

Endocrine disorders in pregnancy 孕期内分泌失调

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-10-01 DOI: 10.1016/j.mpmed.2024.07.008

Endocrine disorders are common in women of childbearing age and are therefore commonly encountered in pregnancy. Physiological adaptions of the endocrine system are essential to meet the demands of pregnancy. Women with pre-existing endocrine disorders require control of their underlying condition to undergo a healthy pregnancy. The clinician must understand the effects that endocrine disorders have on pregnancy, the effects of pregnancy on endocrine physiology and the safety of relevant investigations and medications. In most cases it is appropriate to discuss the management of pre-existing endocrine disorders in pregnancy with the patient during the pre-conception period. Endocrine diseases can present de novo in pregnancy or postpartum, representing a diagnostic challenge, as many symptoms of endocrine diseases overlap with pregnancy symptoms and investigations should be interpreted with consideration of the physiological changes of pregnancy.

内分泌失调是育龄妇女的常见病，因此也是妊娠期的常见病。内分泌系统的生理适应对于满足妊娠需求至关重要。患有内分泌失调的妇女需要控制其潜在的病情，才能健康地怀孕。临床医生必须了解内分泌失调对妊娠的影响、妊娠对内分泌生理的影响以及相关检查和药物的安全性。在大多数情况下，与患者在孕前讨论如何处理妊娠期原有的内分泌失调是合适的。内分泌疾病可在妊娠期或产后新发，这对诊断是一个挑战，因为内分泌疾病的许多症状与妊娠症状重叠，在解释检查结果时应考虑到妊娠的生理变化。

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Neurobiology and principles of addiction and tolerance 成瘾和容忍的神经生物学和原理

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-08-12 DOI: 10.1016/j.mpmed.2024.06.012

Substances of abuse dysregulate key brain systems involved in motivation, reward, decision-making and memory. As drug use evolves into a compulsive addiction, there are adaptations in these systems, mediated by a number of different neurotransmitters. The mesolimbic dopaminergic pathway plays a central role in the reinforcing effects of drugs and the development of addiction. As addiction develops, there is a shift away from positive reinforcement to compulsive, habitual drug-seeking behaviours driven, for example, by craving or aversive withdrawal symptoms. Although the potential for addiction is common to many drugs, the underlying mechanisms, neurotransmission systems and adaptations vary between drugs. This review focuses on the neurobiology of addiction and tolerance for substances including alcohol, benzodiazepines, opioids and stimulants.

滥用药物会使大脑中涉及动机、奖赏、决策和记忆的关键系统失调。当吸毒演变成强迫性成瘾时，这些系统会在多种不同神经递质的介导下发生适应性变化。中边缘多巴胺能通路在毒品的强化作用和成瘾的形成过程中起着核心作用。随着毒瘾的形成，吸毒行为会从正强化转变为强迫性、习惯性的觅药行为，例如受渴求或厌恶性戒断症状的驱使。虽然许多药物都有成瘾的可能性，但不同药物的潜在机制、神经传递系统和适应性各不相同。本综述将重点讨论成瘾和耐受物质的神经生物学，包括酒精、苯二氮卓类、阿片类和兴奋剂。

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Delirium 谵妄

Medicine (Abingdon, England : UK ed.)

Pub Date : 2024-08-10 DOI: 10.1016/j.mpmed.2024.07.002

Delirium is a common neuropsychiatric syndrome. However, it is often misdiagnosed and management can be inconsistent and distressing for patients and their families. It has a diverse multifactorial aetiology and results in cerebral dysfunction. The criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and the International Classification of Diseases, 11th revision, are increasingly unified in describing the core symptoms and profile. The new profiles are characterized by an acute disturbance of attention with a fluctuating pattern and impaired cognition. These profiles then incorporate non-cognitive symptoms, including disordered thinking and hallucinations. Non-pharmacological interventions prioritize staff training, early intervention including physiotherapy, a review of medications and environmental adaptations. Potential pharmacological approaches include the careful use of sedation and low-dose antipsychotics.

谵妄是一种常见的神经精神综合征。然而，谵妄常常被误诊，治疗方法也不一致，给患者及其家属带来痛苦。谵妄的病因多种多样，并导致大脑功能障碍。精神疾病诊断与统计手册》第五版和《国际疾病分类》第 11 版的标准在描述核心症状和特征方面日益统一。新特征的特点是注意力受到严重干扰，且呈波动模式，认知能力受损。这些特征还包括非认知症状，包括思维紊乱和幻觉。非药物干预优先考虑员工培训、包括物理治疗在内的早期干预、药物审查和环境调整。潜在的药物治疗方法包括谨慎使用镇静剂和小剂量抗精神病药物。

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