British journal of hospital medicine最新文献

Aims/background: Myosin heavy chain 9-related disease (MYH9-RD) is a rare inherited disorder characterised by macrothrombocytopenia, often misdiagnosed as immune thrombocytopenia (ITP). Early identification is crucial to prevent unnecessary treatments and to ensure appropriate monitoring. The present case aims to highlight the diagnostic challenges and clinical management of MYH9-RD in a toddler, emphasising the importance of early genetic testing.

Case presentation: We discuss a 13.5-month-old girl with macrothrombocytopenia lacking Döhle bodies, who initially received intravenous immunoglobulin (IVIg) and corticosteroids without any response. Within two months, whole-exome sequencing identified a pathogenic MYH9 mutation (c.287C>T; p.Ser96Leu).

Results: One year later, the patient remains clinically stable without significant bleeding. The occurrence of petechial rash exhibited a more pronounced correlation with platelet mass index (PMI) values compared to platelet count (PLT), underscoring its significance in clinical evaluation.

Conclusion: MYH9-RD should be considered in cases of IVIg-resistant thrombocytopenia accompanied by macrothrombocytes. Timely genetic testing can facilitate accurate diagnosis and may help avoid unnecessary procedures, while routine renal and auditory monitoring is important for managing the S96L variant.

Aims/background: Lobar pneumonia (LP) remains a significant cause of morbidity in children. Early and accurate assessment of the disease severity is crucial for optimal management, yet readily available and specific biomarkers are lacking. This study aimed to analyze the dynamic changes of aspartate aminotransferase/alanine aminotransferase (De Ritis) ratio in children with LP, and to explore their relationship with the disease severity.

Methods: A total of 120 children with LP admitted to the Affiliated Hospital of Xuzhou Medical University from June 2020 to June 2025 were divided into a common pneumonia group (n = 69) and a severe pneumonia group (n = 51) according to the severity of the disease. Hierarchical multiple linear regression was used to analyze the effects of baseline De Ritis ratio, gender, age, body mass index (BMI) and pulmonary lobe lesions on the ΔDe Ritis ratio before treatment and 14 days after treatment. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic efficacy of De Ritis ratio in children with LP before treatment. The dose-response relationship between De Ritis ratio and the condition of LP children was analyzed using a restricted cubic spline. The clinical decision curve was used to analyze the diagnostic efficacy of De Ritis ratio in children with LP.

Results: Repeated measures analysis of variance showed that the De Ritis ratio had significant time effect, between-group effect and time-group interaction effect (all p < 0.001). The De Ritis ratio of the two groups decreased significantly with treatment, with the decline (ΔDe Ritis ratio) being significantly higher in the severe pneumonia group than in the common pneumonia group at each time point (p < 0.05). The results of hierarchical multiple linear regression showed that baseline De Ritis ratio (β < 0), gender, age, BMI and lobar lesions (all β > 0) had a significant effect on De Ritis ratio (p < 0.05). The area under the curve (AUC) for the De Ritis ratio was 0.908, with an optimal cutoff value of 1.52. The restricted cubic spline analysis revealed a non-linear dose-response relationship between De Ritis ratio and LP (p_nonlinear < 0.001). According to the clinical decision curve analysis, De Ritis ratio demonstrated substantial clinical utility in the diagnosis of LP.

Conclusion: De Ritis ratio possesses significant clinical value in the evaluation of LP and its dynamic alterations show a consistent relationship with the severity of the condition.

Aims/background: Studies investigating different classes of vasopressors for septic shock are ongoing, and discrepancies persist among the increasing number of meta-analyses. This umbrella review and evidence map aim to provide a comprehensive overview of the current evidence and to evaluate the highest-quality evidence regarding the efficacy and safety of vasopressors in the treatment of septic shock.

Methods: We searched PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews from inception to August 2024. We included meta-analyses of randomized controlled trials that compared vasopressors for the treatment of adult patients with septic shock. The methodological quality of the included meta-analyses was assessed using A MeaSurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). The quality of evidence for each outcome was evaluated using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The best available evidence was identified using the Jadad decision algorithm.

Results: A total of thirty-one eligible meta-analyses were included. The comparison of norepinephrine with vasopressin was the most frequently studied, followed by comparisons of norepinephrine with dopamine. Norepinephrine was found to be superior to dopamine in reducing mortality, heart rate, and the incidence of arrhythmia. Methylene blue demonstrated a reduction in mortality, even though this finding was supported by low GRADE evidence. Meta-analyses comparing norepinephrine with phenylephrine, epinephrine, and angiotensin II showed no significant differences in mortality, also with low GRADE evidence. The addition of vasopressin to norepinephrine was associated with comparable mortality, a lower risk of arrhythmia, and a higher risk of digital ischemia, with moderate GRADE evidence. In contrast, the addition of terlipressin showed no significant differences.

Conclusion: Current evidence fails to demonstrate superior efficacy of alternative vasoactive agents compared to norepinephrine across all evaluated outcome indicators. Considering both the reduced risk of arrhythmias and the increased risk of digital ischemia associated with vasopressin, clinicians should individualize therapy based on patient-specific factors. In addition, our evidence maps identify gaps in the existing literature, highlighting areas for future research.

Aims/background: With the growing need for high-quality end-of-life care in China, this study aimed to evaluate the practical palliative care skills of nurses across 17 pilot institutions in Hangzhou, identify the key factors influencing these skills, and explore their interrelationships. The ultimate goal was to inform the development of a targeted training and assessment system that can support and enhance palliative care team development in China.

Methods: This study used a convergent mixed-methods design integrating quantitative and qualitative approaches. From February to May 2022, 723 nurses from 17 palliative care pilot institutions in Hangzhou, China, were surveyed using structured scales assessing their palliative care knowledge, perceived difficulty, and self-reported practice. Descriptive, univariate, and multivariate analyses were performed. Semi-structured interviews were subsequently conducted with eight nurses to gain deeper insights into their practical experiences and challenges.

Results: Quantitative findings indicated that palliative care practice competency was at an upper-intermediate level (64.17 ± 15.99). Multivariate linear regression identified gender, age, and willingness to volunteer in palliative care as significantly affecting nurses' palliative care practice ability. Qualitative analysis demonstrated three core themes: (1) cognitive understanding present but specialized knowledge lacking; (2) behavioral gaps in technical skills and symptom management; and (3) structural barriers, including absence of guidelines and restrictive policies. Integrated results highlighted that personal willingness, cognitive awareness, social support, and training opportunities were consistent determinants of competency.

Conclusion: Nurses in Hangzhou demonstrate moderate levels of palliative care competency; however, notable gaps impede high-quality service delivery. There is an urgent need for systematic training, particularly in symptom management and communication skills. Multilevel efforts involving government, healthcare institutions, and the wider community are essential. Priorities include optimizing resource allocation, refining insurance policies, establishing specialized training systems, and enhancing public education to foster informed and rational understanding of end-of-life care.

Aims/background: Deep learning radiomics (DLRadiomics) can capture a wide range of tumor and lesion characteristics, providing valuable insights into biological behavior, pathophysiological status, and patient prognosis. This study integrated clinical data with deep learning-derived features into a machine learning survival model to assess the effectiveness of hepatectomy and transarterial chemoembolization (TACE) treatments in hepatocellular carcinoma (HCC) patients.

Methods: This study included pathologically confirmed HCC patients who received either hepatectomy or TACE between January 2013 and December 2022. We utilized three deep learning-based algorithms (ResNet50, ResNet18, and DenseNet121) with contrast-enhanced computed tomography (CT) images to predict the overall survival time. Deep learning features were extracted from these predictive models. Furthermore, a combined survival model was developed by incorporating clinical factors with the deep learning features for two treatment regimens separately. The areas under the curves (AUC) of the receiver operating characteristic (ROC) curves were used to assess the discrimination of the model at different time points. Additionally, nomograms were constructed to predict patient prognosis undergoing different treatment regimens, and their survival risk was evaluated using the Kaplan-Meier analysis.

Results: This study recruited 409 HCC patients who received either hepatectomy (n = 278, 57 [49-66]; 239 men) or TACE (n = 131, 62 [51-69.5]; 111 men). ResNet50 achieved the highest AUC of 0.866 (95% confidence interval (CI): 0.815-0.917) in the training set and 0.793 (95% CI: 0.675-0.912) in the testing cohort. Overall, six models were constructed to assess overall survival for hepatectomy and TACE treatments, with the combined models exhibiting superior discriminative performance. The C-index for the combined hepatectomy model was 0.836 (95% CI: 0.776-0.897) in the training cohort and 0.861 (95% CI: 0.755-0.967) in the testing cohort. The C-index for the combined TACE model was 0.840 (95% CI: 0.792-0.888) in the training cohort and 0.834 (95% CI: 0.759-0.910) in the testing cohort. Two nomograms were created to help clinicians in selecting a treatment method by examining the difference scores between treatments.

Conclusion: The machine learning models can potentially predict differences in outcomes between hepatectomy and TACE. Furthermore, prognostic models using deep learning-based features can effectively predict survival risk in HCC patients.

Aims/background: Allergic rhinitis (AR) is an upper respiratory disease that affects inflammation levels, nasal function, and mental health in patients. However, the effect of AR severity on these indicators remains obscure. This study aimed to explore the impacts of AR severity on levels of inflammatory factors, nasal function, anxiety and depression.

Methods: The clinical data of 188 patients with AR from January 2022 to January 2025 were collected and retrospectively analyzed. The patients were divided into mild group (n = 90) and moderate/severe group (n = 98) based on the severity of AR. Meanwhile, 79 healthy individuals matched in age, gender, and body mass index (BMI) with the AR patients were included in the control group. Nasal airway resistance (NAR) and nasal mucociliary clearance time (NMCT) were detected. Hospital Anxiety and Depression (HAD) scale was applied for the assessment of anxiety and depression. Serum level of C-reactive protein (CRP) was measured using an automatic biochemical analyzer. Serum procalcitonin (PCT) and nasal lavage fluid levels of interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) were measured using commercial assay kits.

Results: Compared with the control group, the CRP, PCT, IL-1β, TNF-α, NAR, NMCT, and HAD anxiety and depression scores in AR patients were significantly increased (both p < 0.05). Compared with the mild group, the moderate/severe group exhibited increased levels of inflammatory biomarkers, NAR, NMCT, and HAD anxiety and depression scores (p < 0.05). In the mild group, anxiety and depression were correlated with the NAR, CRP, PCT, IL-1β, and TNF-α (p < 0.05); NMCT was correlated with the depression (p < 0.05). In moderate/severe group, anxiety and depression were correlated with the NAR, NMCT, CRP, PCT, IL-1β, and TNF-α (p < 0.05). The correlation between anxiety and depression and nasal function and inflammatory factors in moderate/severe group were stronger than those in mild group.

Conclusion: The anxiety/depression and inflammation levels in AR patients increase, while the nasal function decreases, with the deteriorating severity of the disease. Anxiety and depression are correlated with nasal function and inflammation levels, with a more prominent correlation detected in patients with moderate/severe AR than those with mild disease.

Aims/background: Lipoprotein(a) [Lp(a)] is recognized as a cardiovascular risk indicator; however, its connection to peripheral arterial disease (PAD) in individuals with type 2 diabetes mellitus (T2DM) is not well established. This research seeks to explore how Lp(a) concentrations relate to the occurrence of PAD in T2DM patients.

Methods: A retrospective analysis was conducted on 590 patients diagnosed with T2DM who were admitted to Hefei First People's Hospital from January 2022 to August 2024. Participants were grouped into tertiles according to their Lp(a) levels. The diagnosis of PAD was made using the ankle-brachial index (ABI), with an ABI <0.9 considered indicative of PAD. The association between Lp(a) concentrations and PAD was examined using multivariate logistic regression models, subgroup analyses, receiver operating characteristic (ROC) curves, and restricted cubic spline (RCS) plotting.

Results: Compared to lower Lp(a) levels, the group with higher Lp(a) levels exhibited a higher prevalence of PAD (p = 0.001). Multivariate logistic regression analysis indicated that, after stepwise adjustment for all confounding factors, the risk of PAD in the higher Lp(a) group was 1.961 times that of the lower Lp(a) group (odds ratio [OR] = 1.961, 95% confidence interval [CI]: 1.071-3.588, p = 0.029). Additionally, for each 1 standard deviation increase in Lp(a) or each unit increase in the normalized Lp(a) (Log₁₀Lp(a)), the risk of PAD increased by 25.7% and 80.3%, respectively (OR: 1.257, 95% CI: 1.016-1.555, p = 0.035; OR: 1.803, 95% CI: 1.013-3.209, p = 0.045). Subgroup analysis revealed a stratified association between Lp(a) and PAD risk across multiple subgroups (p < 0.05). ROC analysis demonstrated that Lp(a) had a certain predictive ability for PAD prevalence (area under the curve (AUC): 0.622, 95% CI: 0.568-0.677, p < 0.001). RCS analysis indicated that there was no evidence of a nonlinear relationship between Log₁₀Lp(a) and PAD risk, regardless of the logistic regression model used (p for nonlinearity > 0.05).

Conclusion: A significant correlation was observed between elevated Lp(a) levels and an increased risk of PAD in patients with T2DM.

Aims/background: Acute heart failure (AHF) is a prevalent critical condition in the emergency department. Conventional treatment approaches typically emphasise independent medical practices and lack structured physician-nurse collaborative education, which may adversely impact patient prognosis. This study aimed to evaluate the effectiveness of a physician-nurse collaborative education management model in patients with AHF in the emergency department.

Methods: A retrospective cohort study was conducted on 110 patients with AHF admitted to Tongxiang First People's Hospital between January 2022 and January 2024. The control group (n = 47) received routine care, while the observation group (n = 63) received a physician-nurse collaborative education management intervention. Self-care ability, emotional status, quality of life, New York Heart Association (NYHA) functional classification, N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, length of hospital stay, 3-month readmission rate, and incidence of adverse events were compared between groups.

Results: At baseline, no significant differences were observed between the two groups in the Self-Care of Heart Failure Index (SCHFI), Self-Rating Depression Scale (SDS), Self-Rating Anxiety Scale (SAS), Minnesota Living with Heart Failure Questionnaire (MLHFQ), NYHA functional classification, or NT-proBNP levels (all p > 0.05). Six months after discharge, both groups showed significant increases in SCHFI scores (p < 0.05), with the observation group achieving higher scores (p < 0.001). SDS and SAS scores decreased in both groups, but were significantly lower in the observation group (p < 0.001). MLHFQ scores improved in both groups (p < 0.05), with greater improvement in the observation group (p < 0.001). Furthermore, the observation group demonstrated better NYHA functional classification (p < 0.05), lower NT-proBNP levels (p < 0.05), shorter hospitalisation duration (p < 0.001), and reduced 3-month readmission rates and overall adverse event incidence (p < 0.05).

Conclusion: The physician-nurse collaborative education management model significantly enhances self-care ability, alleviates anxiety and depression, promotes cardiac functional recovery, and improves quality of life in AHF patients. Moreover, it reduces hospitalisation duration, readmission rates, and adverse events, supporting its potential for broader clinical application.