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Introduction: Anti-glomerular basement membrane (anti-GBM) disease is classically diagnosed based on presence of rapidly progressive glomerulonephritis, circulating anti-GBM antibodies, and the hallmark finding of linear IgG deposition along the glomerular basement membrane on kidney biopsy. These deposits are considered a defining feature of the disease, aiding in its differentiation from other pauci-immune glomerulonephritis. However, rare cases lacking IgG deposits on kidney biopsies challenge this paradigm, complicating both diagnosis and management.

Case presentation: We report the case of an 80-year-old male with metastatic rectal cancer, who presented with acute kidney injury, hematuria, and proteinuria. Serological testing confirmed elevated anti-GBM antibody levels. Surprisingly, renal biopsy revealed crescentic glomerulonephritis without characteristic linear IgG deposition, which raised diagnostic uncertainty. Despite the absence of this classic finding, the patient's clinical course was consistent with anti-GBM disease. Given his malignancy, treatment was tailored to balance immunosuppression with oncologic and infectious considerations. The patient received a modified immunosuppressive regimen, including plasma exchange and corticosteroids, but IV cyclophosphamide was withheld due to recurrent infections. Initially, from a nephrology standpoint, his clinical course was notable for partial renal recovery, resolution of hematuria, and improvement in both creatinine and proteinuria levels. However, he ultimately passed away due to severe infectious complications.

Conclusion: This case underscores the diagnostic challenges and therapeutic decision-making in patients who present with features suggestive of anti-GBM disease, characterized by positive anti-GBM antibodies but absent immune deposits, especially when accompanied by malignancy, prior exposure to immunosuppressive therapy, and concurrent infections.

Introduction: Chemotherapy-induced peripheral neuropathy (CIPN) is a common and debilitating consequence for people undergoing treatment for cancer, especially bowel cancer. Painful CIPN contributes to psychological distress, functional decline and reduced quality of life. Additionally, it is a dose-limiting factor for anticancer agents, compromising chemotherapy effectiveness and patient survival. To date, no effective long-term management options exist for painful CIPN. Whilst evidence suggests analgesic effects of repetitive transcranial magnetic stimulation (rTMS), little is known regarding its effectiveness specifically for CIPN-associated pain. The proposed study aims to evaluate the analgesic potential of rTMS in bowel cancer survivors, quantify the duration of symptom alleviation, and explore patient perspectives on using rTMS for CIPN management.

Methods: Participants will be randomised into two parallel groups (allocation ratio 1:1) to receive rTMS or sham stimulation over four sessions, with each session separated by a minimum of 7 days. Pain scores will be obtained immediately before and after each treatment session, as well as at 8-week and 6-month follow-up sessions using the Visual Analogue Scale for Pain (P-VAS) as the primary outcome. P-VAS scores, along with secondary outcome measures of pain and dysaesthesia, will be compared within and between groups across time to assess short-term and long-term effectiveness of rTMS. An interview will be conducted upon completion of all treatment sessions at the 8-week follow-up for qualitative analysis of patients' acceptance of routine rTMS for pain management.

Conclusion: Findings may provide a promising long-term solution to alleviate symptoms of CIPN and enhance quality of life in bowel cancer survivors.

Background: Clinical research involving neonates often presents unique ethical and practical challenges. These difficulties may lead to the early termination of clinical trials, particularly when negative or inconclusive results occur, contributing to publication bias. Failure to report such outcomes ultimately slows the advancement of knowledge and the development of evidence-based care in neonatology.

Summary: This review examines the significance of negative trial results in neonatal clinical research, with particular emphasis on interventional studies, and addresses their reliability, challenges in interpretation, and implications for clinical practice. Insights from selected negative neonatal trials were used to assess the impact of unfavorable outcomes on neonatal care. Non-interventional studies were excluded from this review to maintain a focus on controlled clinical trials.

Key messages: Properly interpreted negative trials hold significant value in neonatal research. These studies help avoid unnecessary interventions, ensuring more efficient use of resources, and guide future research directions. Despite often being undervalued or overlooked, they remain fundamental to advancing evidence-based neonatal care. Enhanced reporting and interpretation of these findings could greatly benefit both clinical practice and research development in the neonatal population.

Introduction: Caregivers are essential for people with dementia (PwD). In Indonesia, families often take on this role due to limited professionals, leading to high stress and burden. This study will evaluate the effectiveness of LESTARI project, a caregiver training program adapted from the WHO iSupport framework, aiming to reduce caregiver stress, reduce BPSD, and increase knowledge about delivering care to PwD. Moreover, caregiver satisfaction with the training program will also be assessed.

Methods: A non-randomized controlled pilot study will involve primary caregivers of PwD, who will be equally assigned to intervention and control groups. The intervention group will participate in the LESTARI project, which comprises seven training sessions based on the Indonesian WHO's iSupport module. Accordingly, three sessions will be conducted face to face along with four online sessions, all comprising lectures, group discussions, relaxation, and self-reflection activities. The primary outcomes include reducing caregivers' stress and improving QoL, BPSD, and caregiving knowledge in the treatment group versus control. Secondary outcomes assess program acceptability, including session content, process, and hybrid delivery.

Conclusion: This study expects the LESTARI training program to reduce caregiver stress, improve quality of life, BPSD, and caregiving knowledge. Secondary outcomes will include caregiver feedback and post-test improvements, supporting feasibility of a hybrid training model as an effective, culturally adapted approach for dementia caregiver support in Indonesia.

Introduction: Ureteroscopic procedures pose a splash hazard to urologists from irrigant contaminated with urine, blood, or caustic substances, risking health and vision. While ureteroscopic adapters aim to minimize fluid leakage, their efficacy remains unstandardized, with high-pressure irrigation potentially generating hazardous spray. This study aimed to evaluate the potential for hazardous leak of various ureteroscopic adapters.

Methods: Six different ureteroscopic adapters were assessed while performing ureteroscopy through a tissue-realistic kidney and ureter model at various levels of pressurized saline generated via a pressure bag and a single-action pumping system (SAPS) with and without a stone basket in the working channel. Leaking was classified as a drip (non-projectile leakage), a spray (small-volume projectile leak), or a splash (large-volume projectile leak). Hazardous spray was defined as any projectile leakage. Ultraviolet fluorescent stain was instilled in the irrigation and utilized to measure the maximal spray distance from the surgeon.

Results: The Gyrus Adjustable Biopsy Port Seal had the highest potential for splash, including at gravity. Other adapters that exhibited hazardous leakage include the Gyrus Blue Silicone Seal with a basket in place and the Merit Hemostasis Valve while under high pressure using SAPS. Only one valve demonstrated no leak under any simulated circumstances (the Medtronic Piton). The Cook Check-Flo Adapter and Boston Scientific Urolok II demonstrated nonhazardous leakage. In the second arm of the experiment, maximal spray distance using the Gyrus Adjustable Biopsy Port Seal was 14.4 feet.

Conclusion: Ureteroscopic adapter leakage can be variable among adapters, and surgeons should be aware of the hazardous potential for exposure.

Introduction: Shunt nephritis is a rare immune complex-mediated glomerulonephritis associated with an infected ventriculoatrial shunt (VAS) or ventriculoperitoneal shunt (VPS). Its incidence has declined to 0.7-2% due to improved infection management. Low-grade bacteremia, particularly from VAS, often involves pathogens such as Cutibacterium acnes, Staphylococcus epidermidis, and Streptococcus species. Immune complex deposition in the kidneys leads to glomerulonephritis and nephrotic syndrome. Early diagnosis and shunt removal, alongside antibiotics, are crucial for renal recovery.

Case presentation: A 35-year-old male with a history of traumatic brain injury and VAS placement presented with generalized edema, hypertension, fatigue, and neurological decline. The patient exhibited nephrotic syndrome with low complement levels. Renal biopsy revealed diffuse membranoproliferative glomerulonephritis with subendothelial deposits. Cerebrospinal fluid (CSF) analysis showed pleocytosis and an elevated albumin ratio, with C. acnes confirmed via blood and CSF cultures. Targeted antibiotic therapy, with first externalization and then removal of the VAS, was followed by a VPS re-implantation after infection resolution. The complement levels normalized, albuminuria decreased, and renal function stabilized.

Discussion: This case highlights the diagnostic challenges associated with shunt nephritis, particularly in the absence of overt infection. Early recognition, targeted antibiotics, and shunt removal are essential for preventing progressive kidney damage and resolving nephrotic syndrome. This case highlights the need for multidisciplinary management in such a complex presentation.

Introduction: There are many reports on atrial fibrillation/flutter (AF) in previous elite endurance athletes (ExA) and veteran athletes (VA), but no prospective studies on AF in elite endurance athletes (EA) have been published. Most studies are on males and increased risk in males has been found, but the explanation of this has been controversial.

Methods: We present a study where 15 male and 15 female EA and matched groups of sports students and non-athletes were studied with clinical examination, a questionnaire, standard ECG, echocardiography, and 24-h ECG (Holter) monitoring in 1985. Twenty-nine EA were re-examined with the same examinations in 2000, and in 2023, a follow-up of 24 of them was done with a questionnaire and ambulatory ECG recording, aiming at the effect of risk factors, training parameters and sex on the occurrence of AF in ExA. The ambulatory ECG recording was done with smartphone (ECG 247) for 72 h or more.

Results: The mean age was 62.6 years. All had ended their competition career before the age of 39. Three had known AF, all males, with the sex difference being significant. Another two males and one female had a history of tachycardia, and the sex difference in total tachycardias was also significant. None of the ExA had asymptomatic AF. A paternal history of AF was significantly more frequent in males with AF than in males without AF. There were no significant sex differences in training parameters.

Conclusions: We think our study does not support doing ambulatory ECG recording of all ExA at age 65, but one should be aware of increased risk in males with a paternal history of AF. Both AF and symptomatic tachycardias were significantly increased in males. However, the low number of AF is a limitation of these conclusions and does not permit concluding on whether training during middle age confers a higher risk of AF than training at a younger age. No sex differences in training in ExA indicate that biological factors (like hormones) contribute considerably to the sex difference in the risk of AF in ExA. Despite the low number of AF cases, we believe our study provides new knowledge as it is prospective, free of baseline selection bias, includes detailed investigations both at baseline and at follow-up, and addresses a gap in prospective studies on AF in EA.

Introduction: During pregnancy, placental microvasculature undergoes significant adaptations to support the developing fetus. However, studying placental microcirculation in vivo remains challenging. This study examined the potential of using retinal microvasculature measurements as a proxy, along with umbilical cord blood markers of angiogenesis and inflammation together with urine cotinine (a nicotine metabolite), to gain insights into the microvasculature changes in the human placenta.

Methods: During the 24-month recruitment period (August 2019 to August 2021), the study was open to all pregnant women receiving antenatal care at Townsville University Hospital in Australia. Immediately after childbirth, the maternal central retinal artery equivalent (CRAE) diameter, the central retinal vein equivalent (CRVE) diameter, and the arteriovenous ratio (AVR) were determined using a handheld non-mydriatic retinal camera. Umbilical cord blood and maternal urine were also collected and analyzed.

Results: Data from 80 women were analyzed. Multivariate analyses found a significant negative correlation between CRAE, CRVE, and tumor necrosis factor receptor 2 (TNFR2) and a significant positive correlation between CRVE and urine cotinine, the diagnosis of preeclampsia, and diabetes mellitus in pregnancy.

Conclusions: We propose that the changes in the retinal artery and vein may reflect alterations in the placenta's spiral artery and its draining vein, with TNFR2 acting as a common mediator.

Introduction: The internet is a major source of medical information for patients, yet the quality of online health content remains highly variable. Existing assessment tools are often labor-intensive, invalidated, or limited in scope. We developed and validated MedReadr, an in-browser, rule-based natural language processing (NLP) algorithm that automatically estimates the reliability of consumer health articles for patients and providers.

Methods: Thirty-five consumer medical articles were independently assessed by two reviewers using validated manual scoring systems (QUEST and Sandvik). Interrater reliability was evaluated with Cohen's κ, and metrics with κ > 0.6 were selected for model fitting. MedReadr extracted key features from article text and metadata using predefined NLP rules. A multivariable linear regression model was trained to predict manual reliability scores, with internal validation performed on an independent set of 20 articles.

Results: High interrater reliability was achieved across all QUEST and most Sandvik domains (Cohen's κ > 0.6). The MedReadr model demonstrated strong performance, achieving R ² = 0.90 and RMSE = 0.05 on the development set and R ² = 0.83 and RMSE = 0.07 on the validation set. All model coefficients were statistically significant (p < 0.05). Key predictive features included currency and reference scores, sentiment polarity, engagement content, and the frequency of provider contact, intervention endorsement, intervention mechanism, and intervention uncertainty phrases.

Conclusion: MedReadr demonstrates that structural reliability scoring of online health articles can be automated using a transparent, rule-based NLP approach. Applied to English-language articles from mainstream search results on common medical conditions, the tool showed strong agreement with validated manual scoring systems. However, it has only been validated on a narrow scope of content and is not designed to analyze search results for specific questions or detect misinformation. Future research should assess its performance across a broader range of web content and evaluate whether its integration improves patient comprehension, digital health literacy, and clinician-patient communication.

Introduction: Health literacy (HL) is crucial in the management of type 2 diabetes mellitus (T2DM), affecting patient outcomes and treatment adherence. Despite its importance, the specific impact of HL on glycemic control remains inconclusive, particularly in Qatar, a country with very high T2DM prevalence. This study aimed to investigate the role of HL as a predictor of disease control among T2DM patients in Qatar.

Methods: This cross-sectional study recruited a random sample of adults with T2DM from the largest healthcare electronic system in the country. Participants were interviewed using a multicomponent questionnaire that included the European Health Literacy Survey Questionnaire (HLS-EU-Q16) and data on demographic and clinical variables. HbA1c <7% was used to define disease control. In addition to bivariate analyses, hierarchical logistic regression analysis was used to assess the association between sociodemographic, clinical variables, HL, and glycemic control.

Results: Among the 450 recruited patients, 55.3% had uncontrolled disease. HL was significantly associated with glycemic control; higher HL scores correlated with lower HbA1c levels with a Spearman's correlation coefficient of -0.624, p < 0.001. Hierarchical logistic regression revealed that HL was a significant predictor of disease control (AOR: 2.192, p < 0.001), after adjusting for sociodemographic and clinical variables.

Conclusion: HL is a key predictor of glycemic control in T2DM patients. Routine HL assessment should be part of diabetes care. Tailored interventions targeting low HL warrant investigation to improve outcomes. Further research is needed to address the effects of low HL in this group.