Postgraduate medicine最新文献

With a constant increase in prevalence and incidence worldwide, stroke remains a public health issue in the 21^st century. Additionally, population aging inevitably leads to increased vulnerability in the general population, a clinical state known as frailty. While there are adequate guidelines on the treatment of stroke in the acute setting, there are a lot of gaps regarding the chronic management of stroke patients, particularly the frail ones. From the therapeutic point of view, palliative care could be the key to offering complex and individualized treatment to these frail chronic stroke patients. In the context of the heterogeneous data and incomplete therapeutic guidelines, this article provides a new and original perspective on the topic, aiming to increase awareness and understanding and improve palliative care management in stroke patients. Based on current knowledge, the authors describe a new concept called the frailty-stroke continuum and offer a detailed explanation of the intricate stroke-frailty connection in the first part. After understanding the role of palliative care in managing this kind of patients, the authors discuss the most relevant practical aspects aiming to offer an individualized framework for daily clinical practice. The novel approach consists of developing a four-step scale for characterizing frail stroke patients, with the final aim of providing personalized treatment and correctly evaluating prognosis. By pointing out the limitations of current guidelines and the challenges of new research directions, this article opens the pathway for the better evaluation of frail stroke patients, offering a better perception of patients' prognosis.

The COVID-19 pandemic has profoundly reshaped postgraduate medical education, driving immediate and significant adaptations in teaching methodologies and educational frameworks. This review examines the multifaceted transformations within medical education environments, particularly in response to the pandemic. Through a structured narrative review of recent literature, we identify key lessons learned and the subsequent shifts in educational practices. Our analysis underscores the critical importance of flexibility in educational delivery, the integration of technology, and the emphasis on mental health and resilience among medical trainees. We also explore the challenges and successes associated with maintaining equality and diversity in a rapidly evolving educational landscape. The findings highlight the necessity for continuous professional development and robust support systems to navigate future challenges effectively. Recommendations are provided for educational institutions to enhance adaptability, foster inclusive learning environments, and prepare for unforeseen global health emergencies. This study aims to contribute to the ongoing discourse on optimizing postgraduate medical education to better prepare health professionals for a dynamic and uncertain future.

Opioids are frequently used first line to manage acute pain in a variety of settings; however, the use of nonprescription analgesics for acute pain is recognized by experts as a practical and effective opioid-sparing strategy. Variations in dosages and formulations and a lack of standardization in reporting clinical data hinder the awareness of nonprescription treatments and recommendation of their use before opioids and other prescription options. A fixed-dose combination (FDC) of two common nonprescription analgesics, ibuprofen (IBU) and acetaminophen (APAP), is an appealing alternative to opioids in acute pain settings with a range of potential benefits. This narrative review evaluates the evidence in support of IBU/APAP FDCs containing IBU (≤1200 mg/day) and APAP (≤4000 mg/day), the nonprescription maximum daily doses in Canada and the United States, as alternatives to opioids and as a means to reduce the need for rescue opioid medication in acute pain management. A literature search was performed to identify clinical studies that directly compared IBU/APAP FDCs with opioids or nonopioids and measured the need for opioid rescue therapy in acute pain. Across studies, IBU/APAP FDCs consistently demonstrated pain relief similar to or better than opioid and nonopioid comparators and reliably reduced the use of rescue opioids with fewer adverse events. Based on these data, healthcare clinicians should consider FDC nonprescription analgesics as a potential first-line option for the management of acute pain.

Nephrogenic diabetes insipidus (NDI) is a rare genetic disorder primarily associated with mutations in the arginine vasopressin receptor 2 (AVPR2) gene or the aquaporin 2 (AQP2) gene, resulting in impaired water reabsorption in the renal tubules. This report describes a case of a young male patient with NDI from China with a history of polydipsia and polyuria for over 15 years. Laboratory examinations of the proband indicated low urine-specific gravity and osmolality. Urologic ultrasound revealed severe bilateral hydronephrosis in both kidneys, bilateral dilatation of the ureters, roughness of the bladder wall, and the formation of muscle trabeculae. The diagnosis of diabetes insipidus was confirmed by water deprivation tests. The administration of posterior pituitary hormone did not alter urine-specific gravity, and osmolality remained at a low level (<300 mOsm/kg). Based on these findings, and the genetic tests of the proband and his parents were performed. A missense mutation (c.616 G>C) in exon 3 of the AVPR2 gene of the proband was found, caused by the substitution of amino acid valine to leucine at position 206 [p.Val206Leu], which was a hemizygous mutation and consistent with X-chromosome recessive inheritance. The administration of oral hydrochlorothiazide improves the symptoms of polydipsia and polyuria in the proband. This novel AVPR2 gene mutation may be the main cause of NDI in this family, which induces a functional defect in AVPR2, and leads to reduced tubular reabsorption of water.

Background: Whether to perform acromioplasty in arthroscopic rotator cuff repair (ARCR) is controversial, and the optimal surgical approach for rotator cuff tear repair is unknown. The purpose of this study was to compare the reoperation rate, retear rate and patient-reported outcomes (PROs) of ARCR with those of ARCR combined with acromioplasty (ARCR-A).

Methods: PubMed, Embase and Cochrane Library were searched for relevant literature dated between database inception and 4 December 2023. The primary outcomes of this study were the reoperation rate and the retear rate. The secondary outcomes were PROs, including the visual analogue scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the University of California-Los Angeles (UCLA) score, the Constant score and the Western Ontario Rotator Cuff (WORC) score. The quality of the included studies was evaluated by using the risk of bias assessment tool. RevMan 5.3 software was used for meta-analysis. Fixed (I² <50%) or random (I² ≥50%) effects models were applied to calculate the effect size.

Results: Meta-analysis revealed that ARCR-A had a lower reoperation rate (OR = 0.35, 95%CI: 0.15-0.85, p = 0.02), but the difference in the retear rate between ARCR-A and ARCR was not significant (p = 0.25). In type 2 acromion patients, the reoperation rate was not significantly different between ARCR and ARCR-A (p = 0.12), but, for type 3 acromion patients, the retear rate was lower for ARCR-A than for ARCR (OR = 0.12, 95%CI: 0.01-0.94, p = 0.04). There were statistically significant differences in the 6-month postoperative Constant scores (p < 0.001), VAS pain scores (p = 0.003) 12-month postoperative ASES scores (p = 0.02) and 24-month postoperative WORC scores (p = 0.04), but these differences were not clinically significant.

Conclusions: Combining ARCR with acromioplasty can reduce the rate of reoperation, especially in patients with type 3 acromion, but it provides no clinically important change in the retear rate and postoperative PRO compared with ARCR.

Introduction: Telemedicine has shown promising results, allowing specialists to provide rapid and effective care in remote locations. However, to our knowledge, current evidence is not robust enough to prove the effectiveness of this tool. This cluster-randomized trial (CRT) aimed to evaluate the impact of telemedicine on clinical care indicators in pediatric intensive care units (PICUs).

Methods: An open-label CRT was conducted in 16 PICUs within the Brazilian public health system. The trial took place from August 2022 to December 2023 and compared an intervention group, which received telemedicine support, with a control group, which received usual PICU care. The primary outcome was the PICU length of stay. The main secondary outcomes were mortality rate and ventilator-free days.

Results: A total of 1393 participants were included, 657 in the control group and 736 in the intervention group. The mean PICU length of stay was 10.42 (SD, 10.71) days for the control group and 11.52 (SD, 10.80) days for the intervention group. The overall mean of ventilator-free days was 6.82 (SD, 7.71) days. Regarding mortality, 7.54% of participants died in total. No significant difference was found in the outcomes between the groups.

Conclusion: Despite the potential benefits of telemedicine, its effective implementation in the Brazilian public health system faces considerable challenges, highlighting the continued importance of investigating and improving the role of telemedicine in pediatric critical care.

Clinical trial registration: ClinicalTrials.gov NCT05260710 and ReBEC - RBR-7×j4wyp.

Background: Legionella maceachernii pneumonia is a severe respiratory infection with low incidence but high mortality. However, the optimal treatment for this disease remains unclear. We report a case of successful treatment of Legionella maceachernii pneumonia, which is the first report of such a case in China.

Case presentation: An 87-year-old man with concomitant chronic obstructive pulmonary disease, liver cirrhosis, and history of left nephrectomy was diagnosed with Legionella maceachernii pneumonia using Dano-seq pathogen metagenomic testing. After two weeks of treatment with cefoperazone/sulbactam combined with quinolone antibiotics, the patient showed improvement and was discharged. The patient continued to take oral quinolone antibiotics for one week after discharge and recovered during outpatient follow-up.

Conclusions: Dano-seq pathogen metagenomic testing can rapidly diagnose Legionella maceachernii pneumonia, and taking quinolone antibiotics is an effective treatment.

Objective: The aim of this study is to examine the perception, willingness to engage, and demand of community residents regarding the 'internet + nursing service' in a designated pilot area, aiming to offer insights for the widespread adoption of the 'internet + nursing service' throughout China.

Methods: A survey pertaining to the 'internet + nursing service' was conducted from March to April 2022. The study specifically targeted residents within two sub-districts of a city in the Jiangsu province. The sampling technique employed in this study was stratified random sampling.

Results: Out of a total of 400 community residents selected from two sub-districts in this region, 378 provided valid responses, resulting in an effective rate of 94.5%. Within the study cohort, 80 participants (21.16%) demonstrated familiarity with the concept of 'internet + nursing service.' Additionally, 231 participants (61.11%) conveyed their willingness to adopt such services. Regarding service preferences, the primary demands were for health guidance, vital sign monitoring, and basic care. Challenges in implementing the service were attributed to concerns related to medical risks, personal safety for both nurses and patients, and potential breaches of privacy.

Conclusions: Residents in the pilot area exhibited a moderate awareness of the 'internet + nursing service,' with a relatively high willingness to embrace the program. There is a need for further refinement of pertinent laws, widespread dissemination of policies, and enhancements in the quality of nursing services. These measures aim to ensure that a greater number of community residents can avail themselves of improved home-based nursing services.

Objectives: Type 2 diabetes mellitus (T2DM) and its microvascular complications are characterized by chronic inflammation. The Controlling Nutritional Status (CONUT) score is a tool used to assess nutritional status and is often associated indirectly with inflammatory processes. We aimed to compare the CONUT scores of T2DM patients with those of healthy volunteers and to compare T2DM patients with and without microvascular complications.

Methods: Patients diagnosed with T2DM and healthy volunteers (as controls) were included in the study. The CONUT score is calculated using the following formula: serum albumin score + total cholesterol score + total lymphocyte count score. CONUT scores of T2DM patients and healthy controls, as well as those of diabetics with and without microvascular complications, were compared.

Results: The CONUT scores of the T2DM and control groups were (1 [0-7]) and (0 [0-2]), respectively (p < 0.001). The sensitivity and specificity of the CONUT score (<1.5 threshold) in detecting T2DM were 43% and 90%, respectively (AUC: 0.67, p < 0.001, 95% CI: 0.64-0.71). Moreover, the CONUT score was an independent risk factor for T2DM (OR: 0.34, p < 0.001, 95% CI: 0.22-0.52). The CONUT score of T2DM patients with microvascular complications (2 [0-7]) was significantly higher than that of T2DM patients without microvascular complications (0 [0-4]) and control subjects (0 [0-2]) (p < 0.001). A CONUT score higher than 1.5 had 83% sensitivity and 92% specificity in detecting T2DM with microvascular complications (AUC: 0.91, p < 0.001, 95% CI: 0.89-0.93).

Conclusion: The CONUT score could be useful in detecting diabetic microvascular complications in clinical practice, as it is an inexpensive and easy-to-assess marker.

Medical education is primarily based on practical schooling and the accumulation of experience and skills, which is important for the growth and development of young ophthalmic surgeons. However, present learning and refresher methods are constrained by several factors. Nevertheless, virtual reality (VR) technology has considerably contributed to medical training worldwide, providing convenient and practical auxiliary value for the selection of students' sub-majors. Moreover, it offers previously inaccessible surgical step training, scenario simulations, and immersive evaluation exams. This paper outlines the current applications of VR immersive teaching methods for ophthalmic surgery interns.