Search Results (299)

Background/Objectives: Pulmonary typical carcinoid (TC) is a rare type of primary neuroendocrine neoplasm of the lung with indolent behavior and a good prognosis. The main treatment strategy is surgery, the extent of which is controversial given the nature of the disease. The aim of this study is to assess whether the extent of resection influences survival and recurrence in patients undergoing lung resection and lymphadenectomy for TC and to investigate negative prognostic factors for OS. Methods: A single-centre retrospective study of 15 years’ experience was conducted. Data from all patients who underwent lung resection and lymphadenectomy for TC were collected. Patients were divided into two groups: anatomical and non-anatomical resections. Perioperative and long-term oncological results were analyzed. Results: In total, 115 patients were surgically treated for TC, of whom 83 (72%) underwent anatomical resection and 32 (28%) non-anatomical resection. Univariate analyses showed that age, left lower lobe, and many comorbidities had a detrimental effect on OS, whereas on multivariate analysis, only left lower lobe location and a high Charlson–Deyo comorbidity index (CCI) were confirmed as negative prognostic factors for OS. At a median follow-up of 93 months (IQR 57-129), the OS survival curves show a slightly lower trend for non-anatomical resections (p 0.152), while no differences were found for DFS. Conclusions: The results of this study confirm that in selected patients at risk for major resections, non-anatomical resection can be used to treat TC when R0 is achievable. These data, together with evidence from the literature, highlight the importance of patient-centred care in this rare disease. Full article

Cardiorenal syndrome (CRS) is a term used to describe the combined dysfunction of the heart and kidneys. This complex disorder is widely acknowledged to be challenging in both its diagnosis and management, and this is the case particularly in the elderly population, due to multi-morbidity, polypharmacy, and age-related physiological changes. Given advancements in medicine and more prolonged cumulative exposure to risk factors in the elderly population, it is likely that the prevalence of chronic kidney disease (CKD) and heart failure (HF) will continue to rise going forward. Hence, understanding the mechanisms involved in the development of CRS is paramount. There are five different CRS types—they are categorised depending on the primary organ involved the acuity of disease. The pathophysiological process behind CRS is complex, involving the interplay of many processes including hemodynamic changes, neurohormonal activation, inflammation, oxidative stress, and endothelial dysfunction and vascular stiffness. The numerous diagnostic and management challenges associated with CRS are significantly further exacerbated in an elderly population. Biomarkers used to aid the diagnosis of CRS, such as serum creatinine and brain natriuretic peptide (BNP), can be challenging to interpret in the elderly population due to age-related renal senescence and multiple comorbidities. Polypharmacy can contribute to the development of CRS and therefore, before initiating treatment, coordinating a patient-centred, multi-speciality, holistic review to assess potential risks versus benefits of prescribed treatments is crucial. The overall prognosis of CRS in the elderly remains poor. Treatments are primarily directed at addressing the sequelae of the underlying aetiology, which often involves the removal of fluid through diuretics or ultrafiltration. Careful considerations when managing elderly patients with CRS is essential due to the high prevalence of frailty and functional decline. As such, in these patients, early discussions around advance care planning should be prioritised. Full article

Aims/Background: Polypharmacy, or the concurrent intake of five or more medications, is a significant issue in clinical practice, particularly in multimorbid elderly individuals. Despite its importance for patient safety, medical education often lacks systematic training in recognising and managing polypharmacy within the framework of patient-centred care. We investigated the impact of a structured learning intervention introducing polypharmacy as a chronic condition, assessing whether it enhances medical students’ diagnostic competence, confidence, and interprofessional collaboration. Methods: A prospective cohort study was conducted with 50 final-year medical students who received a three-phase educational intervention. Phase 1 was interactive workshops on the principles of polypharmacy, its dangers, and diagnostic tools. Phase 2 involved simulated patient consultations and medication review exercises with pharmacists. Phase 3 involved reflection through debriefing sessions, reflective diaries, and standardised patient feedback. Student knowledge, confidence, and attitudes towards polypharmacy management were assessed using pre- and post-intervention questionnaires. Quantitative data were analysed through paired t-tests, and qualitative data were analysed thematically from reflective diaries. Results: Students demonstrated considerable improvement after the intervention in identifying symptoms of polypharmacy, suggesting deprescribing strategies, and working in multidisciplinary teams. Confidence in prioritising polypharmacy as a primary diagnostic problem increased from 32% to 86% (p < 0.01), and knowledge of diagnostic tools increased from 3.1 ± 0.6 to 4.7 ± 0.3 (p < 0.01). Standardised patients felt communication and patient-centredness had improved, with satisfaction scores increasing from 3.5 ± 0.8 to 4.8 ± 0.4 (p < 0.01). Reflective diaries indicated a shift towards more holistic thinking regarding medication burden. The small sample size limits the generalisability of the results. Conclusions: Teaching polypharmacy as a chronic condition in medical school enhances diagnostic competence, interprofessional teamwork, and patient safety. Education is a structured way of integrating the management of polypharmacy into routine clinical practice. This model provides valuable insights for designing medical curricula. Future research must assess the impact of such training on patient outcomes and clinical decision-making in the long term. Full article

Background and Objectives: Severe sepsis complicated by refractory shock is associated with high mortality. Adding continuous hemofiltration to venovenous extracorporeal membrane oxygenation (ECMO) may accelerate clearance of inflammatory mediators and improve haemodynamic stability, but evidence remains limited. We analysed 44 consecutive septic-shock patients treated with combined ECMO-hemofiltration (ECMO group) and compared them with 92 septic-shock patients managed without ECMO or renal replacement therapy (non-ECMO group). Methods: This retrospective single-centre study reviewed adults admitted between January 2018 and March 2025. Demographic, haemodynamic, laboratory and outcome data were extracted from electronic records. Primary outcome was 28-day mortality; secondary outcomes included intensive-care-unit (ICU) length-of-stay, vasopressor-free days, and change in Sequential Organ Failure Assessment (SOFA) score at 72 h. Results: Baseline age (49.2 ± 15.3 vs. 52.6 ± 16.1 years; p = 0.28) and APACHE II (27.8 ± 5.7 vs. 26.9 ± 6.0; p = 0.41) were comparable. At 24 h, mean arterial pressure rose from 52.3 ± 7.4 mmHg to 67.8 ± 9.1 mmHg in the ECMO group (mean change [∆] + 15.5 mmHg, p < 0.001). Controls exhibited a modest 4.9 mmHg rise that did not reach statistical significance (p = 0.07). Inflammatory markers decreased more sharply with ECMO (IL-6 ∆ −778 pg mL⁻¹ vs. −248 pg mL⁻¹, p < 0.001). SOFA fell by 3.6 ± 2.2 points with ECMO versus 1.6 ± 2.4 in controls (p = 0.01). Twenty-eight-day mortality did not differ (40.9% vs. 48.9%, p = 0.43), but ICU stay was longer with ECMO (median 12.5 vs. 9.3 days, p = 0.002). ΔIL-6 correlated with ΔSOFA (ρ = 0.46, p = 0.004). Conclusions: ECMO-assisted hemofiltration improved early haemodynamics and organ-failure scores and accelerated cytokine clearance, although crude mortality remained unchanged. Larger prospective trials are warranted to clarify survival benefit and optimal patient selection. Full article

Background: Chronic pain affects one in five youth globally and is frequently accompanied by mental health challenges that extend into adulthood. Caregivers play a vital role in supporting youth with chronic pain, yet their own mental and physical health needs are often overlooked. While caregiver well-being is linked to child outcomes, few interventions directly address caregivers’ health, especially among those facing systemic barriers. This study explored the lived experiences of caregivers to better understand their unmet needs and inform the co-design of a supportive digital health solution. Methods: We conducted a qualitative exploratory study involving 32 caregivers of youth with chronic pain across Canada and Australia. Semi-structured interviews were co-facilitated by caregiver partners. Thematic analysis was applied to interview data. Results: Two overarching themes were identified: (1) bearing the weight and sacrifice of caregiving and (2) deep interrelatedness and blurred boundaries. Caregivers reported profound emotional, physical, and financial burdens; strained relationships; and social isolation. Many struggled with self-neglect, prioritizing their child’s needs over their own. Fathers’ evolving caregiving roles challenged traditional gender norms, though mothers continued to bear a disproportionate load. Despite challenges, caregivers demonstrated resilience and recognized their well-being as interconnected with their child’s health. Conclusions: Findings underscore the need for systemic investment in caregiver well-being. Digital health solutions, including virtual peer networks, mental health resources, and tailored education, offer scalable, accessible pathways for support. These insights will inform the development of Power over Pain for Primary Caregivers, a digital solution and knowledge hub aimed at improving caregiver well-being and family outcomes, aligning with global efforts to enhance family-centred pediatric pain care. Full article

Sexual dysfunction is a prevalent and often under-addressed concern among prostate cancer survivors, significantly affecting quality of life for patients and their partners. The True North Sexual Health and Rehabilitation eClinic (SHAReClinic) is a virtual, biopsychosocial intervention developed to improve access to sexual health support for prostate cancer survivors and their partners. This study used a qualitative descriptive design to examine barriers and facilitators influencing the integration of SHAReClinic into oncology care across nine Canadian health care centres. Semi-structured interviews were conducted with 17 knowledge users, including health care providers and institutional leaders. Data were analyzed using a hybrid deductive–inductive thematic approach guided by the Consolidated Framework for Implementation Research (CFIR) 2.0. Participants described SHAReClinic as a much-needed resource, particularly in the absence of standardized sexual health pathways in oncology care. The virtual format was seen as accessible and well suited to addressing sensitive topics. However, limited funding, lack of institutional support, and workflow integration challenges emerged as primary barriers to implementation. Findings offer practical, theory-informed guidance for integrating SHAReClinic into oncology care and highlight key considerations for developing sustainable and scalable survivorship care models. Full article

Background: Carcinoma of Unknown Primary (CUP) constitutes approximately 3% of all advanced cancer cases globally, posing a distinct and complex medical challenge due to its metastatic nature, with no identifiable primary tumour site despite comprehensive investigations. Aim: This study aimed to assess the quality of referrals to the Cancer of Unknown Primary Clinic at the Princess Margaret Cancer Centre (PMCC) by conducting a retrospective audit of initial referrals between January 2022 and March 2023. Methods: The adequacy of referrals was evaluated based on adherence to NICE guidelines, focusing on essential diagnostic investigations such as comprehensive history, physical examination, CT scans, and pathological assessment with immunohistochemistry. Our cohort consisted of 97 patients with a median age of 66 years. Results: The results indicated that only 55% of referrals met the criteria for adequacy, with significant deficiencies in computed tomography (CT) scans and immunohistochemistry (IHC). Notably, the adequacy of referrals varied by specialty, with the lowest rates in emergency medicine and family medicine, and the highest rates in medical oncology, gastroenterology, and neurosurgery. Conclusions: These findings underscore the need for improved standardization and education to enhance referral quality, ensuring that patients with CUP receive appropriate and timely care. This study marks the initial phase of the Knowledge-to-Action cycle, highlighting areas for quality improvement in the referral process to the CUP clinic. Full article

To explore Indigenous patients’ use of a primary urgent care centre (PUCC) at a co-located general medical practitioner (GP)-led primary healthcare service (GP service) in regional Queensland, Australia, secondary data analysis was conducted using the 65,420 deidentified PUCC patients from 1 July 2020 to 30 June 2021, including Indigenous status. A Mann–Whitney U test and Chi-Square test were used to analyse patients’ arrival times, reasons to attend PUCC, and frequency of attendance. The proportion of Indigenous patients from the communities attending the PUCC was 9.8% while the proportion of Indigenous people in the general population was only 3.8%. Indigenous patients were more likely to be new patients to the GP service (13.6% never visited the GP service prior to PUCC) compared to non-Indigenous (9.6%) patients. The peak hours of attendance for Indigenous people were 11 a.m.–12 p.m. and 2 p.m.–3 p.m. while it was 10 a.m.–12 p.m. for non-Indigenous patients. The most common reason for attending PUCC for both patient groups was superficial injuries. The second most common reason was digestive issues for Indigenous patients and musculoskeletal issues for non-Indigenous patients. These findings provide insights for enhancing future PUCC models to better meet the community needs, especially the underserved Indigenous population in regional areas. Full article

Background: Mitochondrial DNA (mtDNA) has strong pro-inflammatory potential and was found to be associated with mortality in critically ill patients. The purine bases from circulating cell-free DNA, including mtDNA, are catabolised into uric acid, contributing to elevated systemic levels. However, the prognostic value of uric acid in unselected critically ill intensive care unit (ICU) patients remains unclear. We aimed to investigate the association between uric acid levels at admission and 30-day mortality, assess its correlation with mtDNA, and examine prognostic relevance based on the primary cause of admission. Methods: This prospective single-centre study included 226 patients admitted to a tertiary care ICU. Uric acid and mtDNA levels were assessed at admission. Survival analyses were performed in the overall cohort and in subgroups stratified by primary diagnosis. Results: Uric acid showed a U-shaped association with 30-day mortality, with both low and high levels linked to reduced survival. In multivariate analysis, the 4th quartile of uric acid remained associated with adverse outcomes, independent of sex, vasopressors, mechanical ventilation, and creatinine (HR 2.549, 95% CI: 1.310–4.958, p = 0.006). A modest correlation was observed between uric acid and mtDNA (r = 0.214, p = 0.020). However, prognostic relevance varied by diagnosis. While uric acid predicted mortality in patients following cardiac arrest (p = 0.017), mtDNA was found to bear prognostic value in cardiogenic shock and decompensated heart failure (p = 0.009). Conclusions: Uric acid was independently associated with mortality in critically ill patients, with both low and high levels carrying prognostic value. Its predictive capabilities differed from mtDNA but showed partial overlap. However, both markers exhibited varying prognostic performance depending on the primary cause of admission. Full article

The COVID-19 pandemic disproportionately impacted youth with chronic physical illness (CPI) and their caregivers. Emerging research aimed at understanding the impacts of the pandemic on this population is predominantly quantitative, lacking qualitative insights. This study used a qualitative approach to examine the experiences of COVID-19 among youth with CPI and their families, exploring how the pandemic impacted their mental health and use of mental health services. Using a constructivist paradigm and a phenomenological approach, semi-structured interviews were conducted with youth with CPI (n = 8) and their primary caregiver (n = 13) between March 2021 and May 2021. Thematic analysis was used to identify three key themes: (1) mental health impact on youth, (2) caregiver mental health declines, and (3) variability in the experiences of mental healthcare. The findings highlight the heightened depression, anxiety, and stress among youth with CPI and their caregivers, exacerbated by loneliness, uncertainty, and social restrictions, while also revealing that virtual mental healthcare was perceived as less effective than in-person care, which was valued for its human connection, privacy, and comfort. These results emphasize the need for improved, comprehensive mental healthcare and the adoption of family-centred care models to strengthen caregiver–youth relationships and better integrate physical and mental healthcare to improve health outcomes for this population. Full article

Background: Strategies are needed to address the elevated prevalence of chronic kidney disease (CKD) in socioeconomically disadvantaged regions where obesity, smoking, and type 2 diabetes rates are high. Methods: Recognising the inadequacy of generic health approaches in complex contexts, this study employed a participatory action research (PAR) framework to design and deliver five co-design community workshops in two stages over one year. Stage one workshops identified key matters of concern and stage two focussed on problem solving and co-creating solutions. The goal was to inform health service delivery in a region with high CKD prevalence and explore strategies to overcome barriers to individualised, collaborative care, and promote self-management. Results: The workshops identified three themes: 1. achieving person/family-centred care; 2. multimorbidity and siloed care (stage one); and 3. a kidney wellness framework (stage two). Conclusions: The findings reinforce the need for enhanced care coordination, and highlight the importance of consistent information sources, clear referral pathways, and centralised data sharing among health professionals. The proposed kidney healthcare framework aims to support various professionals, fostering linkages between primary and tertiary care, with an emphasis on professional development, especially in communicating complex information to individuals with multimorbidities. While co-designed healthcare models show promise, challenges persist in effective self-management amidst complex disease information and multimorbidity. Full article

Objectives: Survival from lung cancer is worse in the UK than in some other countries, with late stage at diagnosis implicated in poor prognosis. The route and referral urgency by which patients obtain a diagnosis influence outcomes. This study investigated whether socio-demographic factors are associated with lung cancer routes to diagnosis in England. Materials and Methods: A total of 181,763 primary invasive lung cancers (ICD-10 C34.0-C34.9) diagnosed from 1 January 2012 to 31 December 2016 were abstracted from the English National Cancer Registration Database. Multivariable logistic regression was used to examine associations between patients’ socio-demographic characteristics and likelihood (adjusted odds ratios) of (i) emergency presentation versus all primary care-initiated routes and (ii) urgent (“two-week wait”/2WW) versus standard primary care-initiated referral. Models included the following factors: deprivation quintile of area of residence at diagnosis (IMD income domain); sex; age; ethnic group; rural/urban residence; and (in the emergency model) region. Results: Socio-demographic variations in diagnosis routes were observed. Patients presenting as emergencies (35.2%) were more likely to be 80 years of age or older, female, of non-White ethnicity, and resident in areas of greater deprivation or the London region. In contrast, 2WW patients (28.3%) were more likely to be aged between 50 and 69 years old, of White ethnicity, and resident in an area of greater deprivation or resident outside of an urban centre; diagnosis through 2WW did not vary by sex. Conclusions: Routes to diagnosis are subject to distinct socio-demographic patterning. Action is needed to ensure that new referral guidelines and lung cancer screening roll-out do not widen socio-demographic inequalities in diagnosis. Full article

Background: The ageing of the population and the progressive increase in chronic diseases represent a major challenge for healthcare systems. The community nurse case manager (CNCM) is emerging as a key figure to provide comprehensive and continued care for complex and pluripathological chronic patients (CPCPs), especially after hospital discharge. Objective: The aim of this study is to pilot CNCMs in assisting CPCPs and assess their effects on functional capacity, cognitive performance, quality of life, readmissions, clinical parameters, satisfaction with home care, and caregiver overload. Methods: A comparative study will be carried out at two health centres in Salamanca (Spain). In both centres, CPCPs will continue to receive the interventions included in the Castilla y León Health System Portfolio from their primary care (PC) nurses. In the intervention centre, case management provided by a CNCM will be added. We will recruit 212 CPCPs with cardiac or respiratory disease and/or diabetes mellitus who are dependent for basic activities of daily living and have a programmed hospital discharge. An initial assessment will be performed at home after discharge, followed by assessments at 3, 6, and 12 months. Expected results: The intervention is anticipated to improve all study outcomes. Discussion: CNCMs may contribute to more proactive and individualised follow-up care for CPCPs and their caregivers, improving care coordination. Conclusions: This study will help to evaluate the feasibility and clinical relevance of incorporating the CNCM’s role into PC. This study was registered at ClinicalTrials.gov with the identifier NCT06155591. The date of trial registration was 24 November 2023. Full article

The acquisition of electroencephalography (EEG) concurrently with functional magnetic resonance imaging (fMRI) requires a careful consideration of the health hazards resulting from interactions between the scanner’s electromagnetic fields and EEG recording equipment. The primary safety concern is excessive RF-induced heating of the tissue in the vicinity of electrodes. We have previously demonstrated that concurrent intracranial EEG (icEEG) and fMRI data acquisitions (icEEG-fMRI) can be performed with acceptable risk in specific conditions using a head RF transmit coil. Here, we estimate the potential additional heating associated with the addition of scalp EEG electrodes using a body transmit RF coil. In this study, electrodes were placed in clinically realistic positions on a phantom in two configurations: (1) icEEG electrodes only, and (2) following the addition of subdermal scalp electrodes. Heating was measured during MRI scans using a body transmit coil with a high specific absorption rate (SAR), TSE (turbo spin echo), and low SAR gradient-echo EPI (echo-planar imaging) sequences. During the application of the high-SAR sequence, the maximum temperature change for the intracranial electrodes was +2.8 °C. The addition of the subdural scalp EEG electrodes resulted in a maximum temperature change for the intracranial electrodes of 2.1 °C and +0.6 °C across the scalp electrodes. For the low-SAR sequence, the maximum temperature increase across all intracranial and scalp electrodes was +0.7 °C; in this condition, the temperature increases around the intracranial electrodes were below the detection level. Therefore, in the experimental conditions (MRI scanner, electrode, and wire configurations) used at our centre for icEEG-fMRI, adding six scalp EEG electrodes did not result in significant additional localised RF-induced heating compared to the model using icEEG electrodes only. Full article

Background: adenoviruses (AdVs) are DNA viruses that typically cause mild infections in immunocompetent children, and typically involve the respiratory and gastrointestinal tract. Adenoviral pharyngitis is a common paediatric illness, particularly in children under 4 years old. The aim of our 7-year retrospective study, conducted at a tertiary care paediatric emergency department (ED), was to describe the clinical and laboratory characteristics and management of patients with pharyngeal AdV infections. Specifically, we examined how the management of patients with adenoviral pharyngitis has evolved following the introduction of a rapid antigen nasopharyngeal swab test for AdVs, which has been performed directly in the ED since 2023. Methods: in this single-centre retrospective observational study, the demographic and clinical information for children discharged from the ED who had been diagnosed with a pharyngeal AdV infection between 1 January 2017 and 31 December 2023 were retrospectively reviewed. Moreover, we compared data before and after the introduction of rapid AdV antigenic swabs, which have been directly performed in the ED since the beginning of 2023. Statistical analysis was undertaken using the Student’s t-test and Pearson and Fisher’s exact test, as appropriate. Significance was set at p-value < 0.05. Results: during the study period, 172 children were diagnosed with adenoviral pharyngitis based on a positive swab. All patients were febrile, with a median duration of fever of 4 days. Blood tests were requested for 84.9% of patients at admission, resulting in a mean WBC count of 13,250/mmc and a mean CRP of 70.6 mg/L. The highest CRP median values were found on the third day of fever. Out of 383 swabs performed during 2017–2022, 13.6% were positive vs a 32% positive rate for the 372 swabs performed in 2023. The mean duration of observation in the ED before 2023 was 31.4 h vs. 10.4 h in 2023. Similarly, 9% of patients with adenoviral pharyngitis were admitted to a paediatric ward before 2023 and only 0.8% in 2023. Conclusions: the primary reason for ED admission in cases of adenoviral pharyngitis is fever lasting several days due to hyperinflammation. Differential diagnosis with bacterial infection is essential to limit the number of hospitalisations and inappropriate antibiotic therapy. The introduction of the rapid antigen nasopharyngeal swab has simplified the diagnosis of adenoviral pharyngitis, enabling timely and accurate differentiation from bacterial causes. Full article