British journal of hospital medicine最新文献

Since the advent of the first successful organ transplant, year-on-year recipient numbers have steadily increased in the UK. Unfortunately, however, for each organ transplanted there necessitates an organ to be donated and as such these are extremely precious commodities. This article aims to summarise the management of potential organ donors following brainstem death in the intensive care setting from a UK perspective. A series of predictable pathophysiological changes occur following brainstem death, which if left untreated, can have a catastrophic impact on donor organs and result in them becoming unsuitable for transplantation. The article details the aforementioned pathophysiological changes in order of occurrence, and then discusses their management in line with the recommendations from the NHS Blood and Transplant authority and current literature.

Neuroendocrine neoplasms (NENs) comprise well differentiated neuroendocrine tumours (NETs) and poorly differentiated neuroendocrine carcinomas (NECs). NENs can develop at various anatomical sites, the most common being in the gastrointestinal tract and their incidence is increasing. Although uncommon, they are no longer considered to be rare. Comprehensive biochemical, histopathological and imaging investigations are required to assess an NEN's site, grade and stage and to determine whether it is producing hormones and resulting in a hormonal syndrome. Localised NENs are typically managed with surgery, while metastatic NENs are often treated initially with systemic therapy, such as somatostatin analogue injections. There are multiple options for NEN management, so these patients need to be discussed and managed by a multidisciplinary team of clinicians who have expertise in this tumour type. This article is intended to provide an introduction and summary for clinicians who have little prior experience of NENs.

Distal femoral fractures (DFF) cause significant morbidity and mortality comparable with neck of femur fractures. In view of this, NICE, National Institute of Clinical Excellence, has introduced a Best Practice Tariff (BPT) for management of distal femoral fractures in the elderly to improve morbidity and reduce regional variation of standards. Operative management includes application of external fixation, open reduction and internal fixation, or arthroplasty. While these are associated with significant morbidity, non-operative management may also be considered with immobilisation or traction. A comprehensive multidisciplinary team approach is required for pre-operative assessment, management planning, as well as post-operative rehabilitation. We provide a concise summary on distal femoral fractures covering clinical presentation, management and associated complications, in order to highlight the importance of these injuries and to help develop an understanding as to why they have been prioritised at a national level.

Aims/Background The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted global health and the economy. Vaccination is crucial for controlling its spread, and healthcare workers (HCWs) in Saudi Arabia prioritize vaccination. This systematic review aimed to: (1) evaluate the reported side effects of COVID-19 vaccines among HCWs in Saudi, (2) assess vaccine acceptance rates and their temporal changes, and (3) identify the factors influencing vaccine uptake and hesitancy. Methods We conducted a systematic review following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The protocol included: (1) systematic searching of five major databases (MEDLINE, Embase, PubMed, Scopus, and Web of Science) up to 25 November 2024; (2) independent screening and selection by three reviewers using predefined inclusion criteria; (3) quality assessment using the Joanna Briggs Institute (JBI) critical appraisal tool; and (4) standardized data extraction and synthesis focusing on vaccine side effects, acceptance rates, and influencing factors among healthcare workers in Saudi Arabia. Results Of the 220 citations, 30 met the inclusion criteria. Studies have revealed predominantly mild to moderate side effects, with severity patterns varying by professional role and demographic factors. Vaccine acceptance showed significant improvement over time, which was attributed to public health campaigns, peer influence, and improved accessibility. Higher acceptance was correlated with professional experience and education levels, while hesitancy stemmed from safety concerns and efficacy doubts. Conclusion Understanding these patterns supports the development of targeted interventions, suggesting a need for evidence-based communication and peer-led education programs. Healthcare institutions should focus on transparent safety communication and address specific misconceptions to enhance vaccine confidence among HCWs.

Aims/Background Probiotics, including Bacillus licheniformis, have been shown to mitigate intestinal inflammation and mucositis by modulating gut microbiota and immune responses; however, their role in radiation-induced gastrointestinal (GI) injury remains unclear. This study aims to investigate the effects of Bacillus licheniformis supplementation on radiotherapy-induced GI dysfunction, inflammation, and survival rates in pediatric patients with medulloblastoma. Methods A total of 205 pediatric patients with medulloblastoma admitted to Jinhua Municipal Central Hospital between March 2015 and March 2020 were divided into an experimental group and a control group based on treatment protocols. All patients received craniospinal irradiation (CSI). Patients in the experimental group received an oral Bacillus licheniformis preparation (one capsule, three times daily) starting one day before CSI and continuing through the completion of radiotherapy, while the control group did not receive the probiotic. Post-radiotherapy adverse reactions were recorded. Serum levels of endothelin (ET), C-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), interleukin 1 beta (IL-1β), and interleukin 6 (IL-6) were measured one day before the first radiotherapy session and one day after the final session. A five-year follow-up was conducted to assess patients' survival rates. Results Most of the pediatric medulloblastoma patients developed varying degrees of gastrointestinal symptoms after CSI, with fewer cases observed in the experimental group compared to the control group (all p < 0.05). Serum levels of ET, CRP, TNF-α, IL-1β, and IL-6 significantly increased post-radiotherapy in both groups, but the rise was markedly attenuated in the experimental group (all p < 0.001). However, no significant differences were found in 5-year progression-free survival (hazard ratio [HR] = 1.060, log rank p = 0.716) or overall survival (HR = 1.275, log rank p = 0.350) rates between the two groups. Conclusion Bacillus licheniformis preparation effectively alleviates CSI-induced gastrointestinal dysfunction and inflammation in pediatric patients with medulloblastoma, but does not significantly improve their survival rates.

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia, and given its associations with stroke, heart failure and dementia, AF confers a major impact on public health. Optimal AF management should be based on three pillars: assessment and treatment of stroke risk factors, treatment of comorbidities, and symptom management through rhythm/rate control. In untreated AF, depending on other risk factors, the risk of stroke increases almost fivefold, and one in five strokes is related to AF. Therefore, effective assessment and prevention of stroke are the first pillar of AF management. The basis of stroke prevention is oral anticoagulation, which includes vitamin K antagonists and direct oral anticoagulants. Comorbidities and lifestyle factors exert a substantial influence on the progression risk, course, symptom severity, and prognosis in patients with AF. Hence, the appropriate management of these factors represents a crucial aspect, being the second pillar of AF treatment. The last pillar of AF management is symptom management through rhythm or rate control. Rhythm control in AF encompasses sinus rhythm restoration (antiarrhythmic drugs, cardioversion, and ablation techniques). Conversely, rate control aims to maintain AF while ensuring a well-regulated ventricular rate. Each of these pillars needs regular reassessment and dynamic shared decision-making with patients. The aim of AF treatment is to reduce mortality and improve prognosis and quality of life, which is influenced by each of the three pillars. In addition, it is important to emphasise that each pillar is linked to the others. For example, comorbidities increase the risk of stroke, and inadequate rhythm/rate control can accelerate the development of heart failure. Therefore, treatment of AF must not be punctual, but holistic and personalised, as outlined in this review.

Aims/Background Patients with acute Stanford type A aortic dissection (ATAAD) face particularly high risks of prolonged mechanical ventilation and weaning failure due to the combined effects of surgical trauma, systemic inflammation, and multi-organ involvement. However, current weaning predictors are primarily derived from general cardiac surgery populations, leaving ATAAD-specific evidence limited. This study investigated the factors influencing postoperative mechanical ventilation weaning outcomes in ATAAD patients and constructed a prediction model. Methods We retrospectively analyzed 120 postoperative ATAAD patients requiring mechanical ventilation at Nanjing First Hospital between January 2020 and March 2022. Patients were categorized into a weaning success group (n = 79) and a weaning failure group (n = 41) based on their weaning outcomes. Clinical variables were compared between groups, and multivariate logistic regression analysis was performed to identify independent predictors of weaning failure. Multicollinearity was assessed using variance inflation factors (VIFs). A nomogram prediction model was developed, and its performance was evaluated using the C-index, receiver operating characteristic (ROC) curve analysis, calibration plots, and decision curve analysis (DCA). Results Multivariate logistic regression identified a history of chronic obstructive pulmonary disease (COPD) (p = 0.002), a history of kidney disease (p = 0.002), increased intraoperative blood loss (p = 0.037), elevated postoperative 24-hour serum creatinine (Scr) (p < 0.001), and elevated brain natriuretic peptide (BNP) levels (p = 0.009) as independent risk factors for weaning failure from mechanical ventilation in ATAAD patients. An increased respiratory rate (p = 0.003) was a protective factor. Multicollinearity testing revealed that VIF values for all six variables were <5 (1.018-1.050), indicating no significant collinearity. The nomogram model demonstrated good discrimination (C-index = 0.806, 95% confidence interval [CI]: 0.752-0.859; with an area under the curve [AUC] = 0.80 (95% CI: 0.72-0.88, p < 0.001), with a sensitivity of 92.13% and specificity of 67.86%. The calibration curve showed strong agreement with the ideal model. DCA indicated a significant net clinical benefit at thresholds above 0.2, confirming the clinical utility of the model. Conclusion Mechanical ventilation weaning failure is a frequent and clinically significant complication after ATAAD surgery. Its risk is associated with a history of COPD, a history of kidney disease, intraoperative blood loss, postoperative Scr, BNP, and respiratory rate. The constructed nomogram accurately predicts weaning outcomes, offering valuable support for individualized risk assessment and clinical decision-making in ATAAD patients.

Langerhans cell histiocytosis (LCH) is a rare, life-threatening condition that predominantly affects children. It is a diagnostically challenging condition due to several different clinical presentations. Presentations of LCH with otological involvement are considered rare. We report a case where LCH presented a six-month-old boy to our tertiary teaching hospital. The patient presented with a unilateral left postauricular soft tissue mass, with an associated left external ear canal lesion and middle ear effusion, which initially had the working diagnosis of mastoiditis. However, further imaging and molecular testing concluded the final diagnosis as LCH with multisystem involvement. When LCH does have otological involvement, it commonly involves the external and the middle ear, which can often be confused with otitis media and otitis externa. This case report highlights that misdiagnosis of LCH can occur due to its broad presentation. The case report also raises the importance that in cases of unilateral postauricular soft tissue masses with destructive findings on cross-sectional imaging and systemic symptoms and signs, LCH must be a differential diagnosis, and biopsy should be considered.

Aims/Background Bloodstream infection (BSI) is a life-threatening condition, and early, accurate pathogen identification is essential for improving patient outcomes. Conventional blood culture (BC) methods have notable limitations, including low sensitivity, prolonged turnaround time, and susceptibility to prior antibiotic exposure. This study aimed to evaluate the diagnostic performance and clinical value of digital polymerase chain reaction (dPCR) in patients with suspected BSI. Methods This retrospective study included 294 patients with suspected BSI admitted to the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, between January 2021 and April 2022. All patients underwent BC and dPCR testing. dPCR was performed using a multiplex bacterial nucleic acid detection kit targeting Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa. BC results served as the reference standard, and discordant findings were resolved using Sanger sequencing. Sensitivity, specificity, overall agreement, and Kappa coefficients were analysed. The diagnostic efficacy of dPCR for localised infections was assessed, and univariate and multivariate logistic regression analyses were conducted to evaluate clinical predictors of dPCR positivity. Results Compared with BC, dPCR demonstrated a significantly higher positivity rate (41.5% vs. 12.2%). Validated against BC plus Sanger sequencing, dPCR achieved near-perfect sensitivity (99.18%) and specificity (99.42%), with an overall agreement of 99.32% (Kappa = 0.99). dPCR identified substantially more true-positive cases missed by BC (86 additional true positives and only one false positive). These patients had pathogens identified in other tissue samples, supporting the value of dPCR in early detection of occult infections. Multivariate analysis revealed elevated procalcitonin (PCT) as an independent predictor of dPCR positivity. The receiver operating characteristic (ROC) curve for PCT predicting dPCR positivity yielded an area under the curve (AUC) of 0.656 (95% confidence interval [CI]: 0.592-0.720, p < 0.001), with an optimal cut-off of 6.11 ng/mL. Conclusion dPCR demonstrates high sensitivity and accuracy for BSI diagnosis, allowing earlier detection of occult infections missed by conventional methods. Guided by clinical risk factors such as PCT, dPCR may refine diagnostic and treatment pathways for BSI.