Journal of Clinical Medicine最新文献

Background: Diabetic foot osteomyelitis (DFO) is a severe complication requiring effective empiric antibiotic therapy to prevent amputation. While global guidelines suggest tailoring therapy based on climate zones, limited data exist regarding seasonal variations within a single region experiencing distinct seasonal extremes. This study investigated whether the bacterial etiology of DFO differs significantly between the hot, humid summer and the cold, dry winter in the Republic of Korea. Methods: We conducted a retrospective cohort study of 85 patients with DFO who underwent lower extremity amputation between January 2018 and October 2024. Patients were categorized into Summer (July-August) and Winter (December-January) groups. Deep tissue or bone specimens were analyzed to compare pathogen prevalence. Results: A total of 85 patients were included (Summer: n = 45; Winter: n = 40). While Staphylococcus species were the most common pathogens overall (30.6%), a seasonal shift was observed. The proportion of Gram-negative isolates was higher in Summer (50.7%) compared to Winter (35.1%), representing a notable clinical trend (p = 0.080). Specifically, Pseudomonas aeruginosa and Escherichia coli were more frequently isolated during the summer months. Furthermore, polymicrobial infections were more prevalent in Summer (62.2%) compared to Winter (45.0%), although this did not reach statistical significance (p = 0.111). Conclusions: The microbiological profile of DFO exhibits seasonal variations. The observed trend toward an increased prevalence of Gram-negative and polymicrobial infections during the Korean summer suggests that empiric antibiotic guidelines should be dynamic rather than static.

Background: HyperCKemia, defined as elevated serum creatine kinase, commonly reflects muscle injury but may also indicate underlying metabolic disease. Metabolic aetiologies, including glycogen storage disorders, fatty acid oxidation defects, mitochondrial cytopathies, and purine metabolism disorders, are clinically important owing to diagnostic complexity, therapeutic implications, and potential reversibility.

Objective: To summarise current evidence on metabolic causes of hyperCKemia in adults, with emphasis on disorders of carbohydrate, lipid, and purine metabolism and mitochondrial disease.

Methods: Semi-systematic narrative review of pathophysiology, clinical features, diagnostic approaches, and management of metabolic disorders associated with hyperCKemia.

Results: Metabolic myopathies often present with nonspecific or exercise-related symptoms, with creatine kinase levels ranging from mild-to-severe elevations. Conditions such as McArdle disease, carnitine palmitoyltransferase II deficiency, and mitochondrial cytopathies demonstrate characteristic metabolic vulnerabilities leading to episodic or persistent hyperCKemia. Medications, including statins and antiretrovirals, may precipitate symptoms in predisposed individuals. Diagnosis requires a structured, multidisciplinary approach incorporating biochemical testing, genetic analysis, functional studies, and muscle biopsy. Many causes are amenable to targeted therapy, including dietary modification, endocrine correction, and medication withdrawal.

Conclusion: Metabolic causes of hyperCKemia are under-recognised but clinically significant. Early identification allows targeted treatment and prevention of complications.

Background: Continuity of care for rheumatoid arthritis patients within regional networks enables stable long-term clinical data collection, despite chronic rheumatologist shortages in Japan. We determined 5-year drug survival and discontinuation reasons for eight biological disease-modifying antirheumatic drugs (bDMARDs) using a regional multicenter registry. Methods: We retrospectively analyzed 1182 patients initiating their first (naïve, n = 784) or subsequent (switch, n = 398) bDMARD between May 2001 and August 2022 across five institutions. The primary endpoint (5-year drug survival) and secondary endpoints (discontinuation risk factors and cumulative incidence of reasons) were evaluated using Kaplan-Meier curves, Cox proportional hazards, and Fine & Gray models. Results: Baseline characteristics varied significantly among bDMARDs. Five-year drug survival in the naïve cohort ranged from tocilizumab (50.8%) to golimumab (22.6%); in the switch cohort, from abatacept (42.6%) to infliximab (10.0%). In multivariable Cox analysis of naïve patients, male sex (hazard ratio [HR] = 1.49, 95% confidence interval [CI] = 1.09-2.02), lower baseline 28-joint Disease Activity Score with erythrocyte sedimentation rate (DAS28-ESR) (HR = 0.90, 95% CI = 0.82-0.99), and absence of methotrexate co-therapy (HR = 0.73, 95% CI = 0.55-0.97) predicted discontinuation. The lower baseline DAS28-ESR association potentially reflects successful courses toward intentional cessation following remission. Discontinuations were attributed to inadequate response (27.1%), non-adverse events (25.3%), and adverse events (17.3%). Conclusions: Tocilizumab and abatacept demonstrated the highest retention rates in biologic-naïve and switch cohorts, respectively. Early, individualized drug selection and dose optimization are crucial to maximizing long-term bDMARD effectiveness before switching.

Background/Objectives: Shear wave elastography (SWE) has emerged as a quantitative imaging technique for assessing muscle mechanical properties and has been increasingly applied to post-stroke spasticity. However, the clinical validity of SWE relative to established clinical spasticity scales and the influence of assessment protocols remain incompletely understood. This systematic review and meta-analysis aimed to evaluate the clinical validity of SWE for post-stroke spasticity and to identify clinically relevant methodological moderators. Methods: A systematic literature search was conducted in PubMed, Cochrane Library, CINAHL, and Web of Science to identify studies reporting correlations between SWE measures and clinical spasticity scales in individuals with stroke. Random-effects meta-analyses were performed using robust variance estimation to account for dependent effect sizes within studies. Prespecified subgroup and meta-regression analyses examined potential moderators, including clinical scale, muscle position during assessment, output metric, limb segment, and stroke chronicity. Results: Ten studies involving 303 participants contributed 38 correlation estimates. The pooled correlation between SWE and clinical spasticity scales was moderate (r = 0.42, 95% CI 0.34-0.49). SWE demonstrated significantly stronger correlations with the Modified Tardieu Scale than with the Modified Ashworth Scale. Measurements obtained in stretched muscle positions showed higher validity than those obtained at rest. Other examined moderators were not statistically significant. No evidence of publication bias was detected. Conclusions: SWE shows a moderate association with clinician-rated spasticity scales and appears to reflect the mechanical consequences of post-stroke spasticity. Associations were influenced by scale selection and measurement position. These findings support protocol-informed integration of SWE as a quantitative adjunct for assessing passive muscle stiffness rather than as a replacement for established clinical scales.

Background/Objectives: To analyze possible epigenetic changes (miRNA) in systemic lupus erythematosus (SLE) patients on a Mediterranean diet (MD) supplemented with extra virgin olive oil (EVOO). Methods: Fifteen SLE patients with medium/high MD adherence were randomized into an intervention group (IG) (daily supplementation of 40 mL of EVOO for 24 weeks) or to a control group (CG). miRNA profiles from blood peripheral cells were analyzed pre-/post-intervention using next-generation sequencing. Differential expression analysis was performed by DESeq2 in R to determine changes in the log2FC. Functional enrichment analysis was performed using GeneCodis 4. Results: EVOO supplementation resulted in changes in the expression of 16 miRNAs in the IG. Compared to the CG, two miRNAs showed upregulation (miR-451a, miR-1307-5p) while five showed downregulation (miR-193b-50, miR-134-5p, miR1287-5p, miR-124-3p, miR-654-3p). miR-124-3p, which has been proposed to be an SLE biomarker, showed the lowest relative expression after EVOO supplementation (L2FC -3.36; p_unadj = 0.025), whereas miR-1307-5p (L2FC 1.115 p_unadj = 0.02) and miR-451a (L2FC 0.77 p_unadj = 0.036) showed the highest relative abundance. The functional enrichment analysis showed that Th1 and Th2 cell differentiation and the complement/coagulation cascades were among the top ten most significantly enriched pathways. Conclusions: Our data suggest that MD supplementation with EVOO leads to changes in the profile of miRNAs in SLE patients, potentially impacting disease pathogenesis. Further research is needed to validate these preliminary findings and the mechanisms by which EVOO modifies miRNA expression in the context of this disease.

Background/Objectives: Prophylactic mastectomy can significantly reduce the risk of breast cancer in patients carrying gene mutations such as BRCA1 and BRCA2. Patients who opt for breast removal are offered tailored reconstructive options based on their medical history and prior treatments, and in these often young patients with limited autologous tissue reserves, implant-based reconstruction is frequently the option of choice. Complication rates of these procedures are relatively high and account for up to 30%. Subcutaneous mastectomy with primary implant reconstruction carries risks such as hematoma, seroma, skin necrosis, necrosis of the nipple-areola complex, and wound healing issues, which may necessitate revision surgery. This university-center retrospective analysis aims to improve outcomes by identifying patient- and surgery-related risk factors associated with postoperative complications in allogenic breast reconstruction following subcutaneous mastectomy. Methods: We analyzed 61 female patients and 122 breasts who underwent primary implant-based reconstruction after skin- or nipple-sparing subcutaneous mastectomy over three years between January 2021 and December 2023. Demographic and surgical variables were systematically collected and analyzed. Results: The mean patient age was 41.5 ± 10.3 years. A total of 13% of patients were active smokers, and 1.6% had diabetes mellitus. Overall, skin flap necrosis occurred in 27.9% of patients (22.1% of breasts), wound healing disorders in 19.7% of patients, wound infections in 9.8%, and revision surgery in 18.0%. A history of pregnancy was associated with skin flap necrosis (OR 10.07, 95% CI 1.79-190.06; p = 0.032); however, this finding must be interpreted with caution due to limited statistical power and model instability. Conclusions: This investigation revealed clinically relevant patterns suggesting potential risk factors for wound healing disorders and skin necrosis. Prospective studies are planned to further substantiate these findings and to help reduce overall complication rates associated with the procedure.

Background: Sinonasal mucosal melanoma is a rare and aggressive malignancy arising from the nasal cavity and paranasal sinuses, characterized by high local recurrence rates and poor survival. Skull-base and orbital progression can occur rapidly, particularly when preoperative imaging underestimates local extension. This paper reports a case of sinonasal mucosal epithelioid melanoma with fulminant postoperative skull-base breach and orbital invasion, highlighting its clinical course, management challenges, and histopathological features. Methods: A 60-year-old woman with progressive unilateral nasal obstruction, recurrent epistaxis, and headache underwent clinical evaluation, contrast-enhanced head MRI, CT, and PET-CT staging. Preoperative imaging demonstrated no intracranial or orbital invasion. Biopsy confirmed mucosal epithelioid melanoma with high proliferative activity (Ki-67 ~80-85%). The patient underwent extensive image-guided endoscopic resection with intraoperative cerebrospinal fluid leak repair. Results: Definitive histopathology confirmed pigmented epithelioid melanoma with extensive necrosis, bone invasion, and non-assessable resection margins due to specimen fragmentation (pT4a, Rx). Within two weeks postoperatively, CT and MRI demonstrated extensive local recurrence with cribriform plate destruction, anterior skull-base dural infiltration, and rapid orbital progression with optic nerve compression and loss of vision. Despite hemorrhage control and hypofractionated palliative radiotherapy (VMAT, 33 Gy in 11 fractions), the patient experienced progressive neurological decline, refractory pain, and recurrent tumour bleeding, and died approximately 4.5 months after initial presentation. Conclusions: In patients with sinonasal mucosal epithelioid melanoma, fulminant local progression with skull-base and orbital involvement may occur despite apparently limited preoperative imaging. When rapid vision loss, dural infiltration, and refractory nasal bleeding develop, structured palliation, hemorrhage control, and aggressive multimodal analgesia should be prioritized early alongside ongoing multidisciplinary decision-making.

Background: Laryngospasm is defined as glottis closure due to reflex constriction of the laryngeal muscles. It is one of the most common complications following pediatric anesthesia that can lead to hypoxemia, bradycardia, or aspiration. Laryngospasm following tracheal extubation has different reasons: presence of secretions, foreign body in the airway, or pain at the site of surgery. Propofol is usually used as an induction or maintenance agent. However, its use with the subhypnotic dose (0.5 mg/kg) is increasing nowadays for reducing the incidence of laryngospasm. This systematic review and meta-analysis aim to assess the efficacy of subhypnotic propofol in reducing the incidence of laryngospasm and respiratory complications in children following tonsillectomy or adenotonsillectomy and before extubation. Methods: We systematically searched the following databases: PubMed, Cochrane Library, Scopus, and Web of Science. Studies were included if they used propofol with a low dose (0.5 mg/kg) following tonsillectomy and before extubation. Both Randomized Controlled Trials (RCTs) and cohort studies published up until 27 December 2025 were included. We used the R software for statistical analysis. We employed a random-effects model for the analysis. Continuous outcomes were analyzed as mean differences (MD) and dichotomous data as risk ratios (RR), with 95% confidence intervals (CI). Heterogeneity was assessed using I² statistics. Results: Our review included four RCTs and one prospective cohort study with 593 participants. Our analysis showed that propofol was significantly associated with a low incidence of laryngospasm (RR = 0.25, 95% CI 0.13-0.49), cough (RR = 0.08, 95% CI 0.01-0.62), and agitation (RR = 0.15, 95% CI 0.03-0.72) compared with the control group. However, there were no significant differences regarding laryngeal occlusion (RR = 0.70, 95% CI 0.20-2.46), cyanosis (RR = 1.13, 95% CI 0.14-9.43), stridor (RR = 1.38, 95% CI 0.76-2.50), and the duration of surgery (MD = 1.81, 95% CI -0.74 to 4.36). Conclusions: Our findings state that propofol had a lower significant incidence of laryngospasm than the control. Trial sequential analysis for laryngospasm indicated that evidence is conclusive. However, regarding the other outcomes, the evidence is still inconclusive, which suggests the need for future large-scale RCTs with larger sample sizes to validate these findings.

Background/Objectives: Cervical pain is defined as pain in the neck that may or may not radiate to one or both upper extremities and lasts at least one day. Headaches are within the spectrum of neck pain, defined as any painful sensation perceived in the head that can extend to the neck. They are classified as primary (migraines and tension headaches) or secondary (cervicogenic headaches) depending on their clinical presentation and associated symptoms. The objective of this review is to compare the effects of dry needling with and without spinal manipulative techniques versus the application of other physical therapy modalities. Methods: A systematic review was conducted searching articles compatible with the objectives of this study in PubMed, ScienceDirect, and Scopus databases using the search terms spinal manipulation, cervical manipulation, dry needling, headache, headaches, and migraine over the last five years and combined with the Boolean operators AND and OR. After screening, all studies underwent methodological quality assessments using the PEDro scale and qualitative synthesis for study design, patients' characteristics, interventions, comparators, outcomes assessed and main results data. Results: Thirteen randomized clinical trials were selected. The quality of the studies is varied, with PEDro scale values ranging from six to eight. Dry needling and cervical manipulations have proven to be effective tools, compared to other interventions, in reducing pain and improving functionality in patients with headaches. Conclusions: Dry needling techniques and manipulations have shown significant effects on parameters related to pain, sensitivity, functionality, and general health in patients with headaches. However, future studies are necessary to more deeply analyze the long-term effects of both techniques.

Introduction & Objective: Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT), with limited treatment options for steroid-resistant cases. Ruxolitinib, a JAK1/2 inhibitor, has shown promise in treating steroid-resistant acute (aGVHD), chronic (cGVHD), and overlap GVHD (oGVHD), but real-world data remain limited. This study evaluated the real-world efficacy and safety of ruxolitinib in allo-HSCT patients with steroid-resistant GVHD. Materials & Methods: This retrospective, multicenter study included adult patients treated with ruxolitinib for Grade II or higher aGVHD or moderate-to-severe cGVHD at nine centers in Turkey (2017-2024). Clinical characteristics, treatment responses, and adverse events were recorded. Primary outcomes were overall response rate (ORR) and overall survival (OS). Results: Among 80 patients (mean age: 39.3 ± 13.3 years; 60 males), 39 had aGVHD, 68 cGVHD, and 15 oGVHD. The ORR was 72 of 80 patients (90.0%) (complete response: 37 of 80 [46.3%], partial response: 35 of 80 [43.8%]). The 1-year and 2-year OS rates were 91.3% and 82.5%. Severe cGVHD (p < 0.001) and lack of response to ruxolitinib (p = 0.018) were associated with reduced OS. Adverse events included infections in 40 of 80 patients (50.0%), cytopenias in 23 of 80 (28.7%), and cytomegalovirus reactivation in 20 of 80 (25.0%). Conclusion: In this retrospective multicenter cohort, ruxolitinib was associated with high response rates in steroid-refractory GVHD, while disease severity remained a key determinant of survival, and findings should be interpreted as exploratory.