Journal of Clinical Medicine最新文献

Background/Objectives: Infliximab (IFX) is commonly used in chronic inflammatory conditions of the ileo-anal pouch. A subcutaneous (SC) formulation has been developed, with studies in inflammatory bowel disease (IBD) patients showing that switching from intravenous (IV) to SC IFX is safe with a low risk of relapse. However, so far, it has not been specifically investigated in chronic inflammatory pouch conditions. The aim of our study was to evaluate the effectiveness and safety of SC IFX in patients with chronic inflammatory pouch conditions. Methods: This was an observational retrospective study. We included patients with chronic inflammatory pouch conditions, initially treated with IV IFX and subsequently switched to SC IFX, who had a follow-up of at least 1 year. The primary outcome was SC IFX treatment persistence, defined as continuation of SC IFX throughout the study period. The secondary outcome was pouch failure, defined by the need for a defunctioning ileostomy or pouch excision. Results: A total of seven patients were included. The mean age was 50.6 years. The average follow-up length was 101.3 months (range 70.4-132.6 months). All seven patients continued SC IFX throughout the study period. No patient experienced pouch failure. The median IFX serum concentration was 18.1 mg/L. There were no cases of serious infections or malignancy. Conclusions: Switching clinically stable patients with chronic inflammatory pouch conditions from IV to SC IFX formulation appears feasible. These findings warrant confirmation in larger patient cohorts.

Background/Objectives: Frontal sinus fractures are uncommon injuries that may cause persistent aesthetic deformity when the anterior wall is comminuted, as small irregular fragments are difficult to stabilize with conventional osteosynthesis alone. Methods: We describe a point-of-care digital workflow combining 3D planning/printing and cyanoacrylate-assisted fixation for an isolated comminuted anterior frontal sinus wall fracture. A young adult presented with a depressed forehead contour after assault; computed tomography confirmed at least four displaced fragments. Results: A two-part 3D-printed biomodel was manufactured in-house to visualize the defect and guide extracorporeal reconstruction. Through a coronal approach, fragments were mobilized and anatomically reassembled using the biomodel as a reference; sinonasal drainage was preserved and sinus obliteration was not required. Because fragment size and geometry limited screw purchase, a modified N-butyl-2-cyanoacrylate adhesive (Glubran 2) was applied as an adjunct to maintain reduction, followed by reinforcement with titanium microplates. Postoperative recovery was uneventful, with immediate restoration of forehead contour and no early complications; postoperative imaging confirmed satisfactory alignment. Conclusions: This case supports the feasibility of integrating point-of-care 3D biomodeling with cyanoacrylate as a coadjuvant to microplate fixation in selected comminuted frontal sinus fractures to enhance fragment handling and contour restoration.

Background: The risk of morbidity and mortality increases in newborns requiring postpartum transport. Various scoring systems have been developed to determine mortality risk, such as the Transport Risk Index of Physiologic Stability (TRIPS) and Mortality Index for Neonatal Transportation (MINT) scores. This study aimed to evaluate the efficiency of MINT and TRIPS scores by comparing them with the Score for Neonatal Acute Physiology-Perinatal Extension (SNAPPE-II) scoring system in preterm and term infants transported within the first 24 h after birth. Methods: This retrospective study included neonates transported within the first 24 h of life to the NICU of Etlik Zübeyde Hanım Women's Health Training and Research Hospital between 2016 and 2021, following ethics approval. Perinatal data, admission clinical and laboratory parameters, and TRIPS, MINT, and SNAPPE-II scores calculated within the were recorded. Mortality and short-term morbidities were analysed. Group comparisons were conducted using Mann-Whitney U and chi-square tests. Predictive performance and optimal cut-off values were determined by receiver operating characteristic curve analysis using the Youden index. p value <0.05 was considered significant. Results: A total of 137 newborns were included in the study. Seventy-two cases (52.6%) were preterm, and 65 cases (47.4%) were term newborns. The median gestational age and birthweight were 35.6 weeks and 2485 g, respectively. A total of 10 patients died. For mortality prediction, the areas under the curve for TRIPS, MINT, and SNAPPE-II were 0.919, 0.907, and 0.973, respectively (p < 0.001). The determined cut-off values for TRIPS, MINT, and SNAPPE-II were >19, >4, and >35, respectively. The TRIPS score showed the best accuracy for prediction of mortality in preterm infants. Conclusions: Our data show that MINT and TRIPS scores are efficient beyond SNAPPE-II. They demonstrated high diagnostic effectiveness in predicting mortality in preterm and term infants. The TRIPS score exhibits superior mortality prediction in preterm infants.

Introduction: Metabolic acidosis is common after kidney transplantation and is associated with adverse outcomes. However, its vascular and functional correlates in kidney transplant recipients remain insufficiently characterized. Methods: We conducted a cross-sectional study of adult kidney transplant recipients attending routine outpatient visits at a tertiary transplant center. Metabolic acidosis was defined as serum bicarbonate < 22 mmol/L. Arterial stiffness was assessed by carotid-femoral pulse wave velocity (PWV), and physical frailty was evaluated using the Fried frailty phenotype. Multivariable regression models were used to identify determinants of metabolic acidosis and to examine its association with arterial stiffness and frailty severity. Results: Among 239 patients (median age 46 years), 154 (64%) had metabolic acidosis. Lower estimated glomerular filtration rate and higher systemic inflammation were independently associated with metabolic acidosis. Metabolic acidosis was independently associated with higher arterial stiffness, with a 1.41 m/s higher PWV after adjustment for age, sex, blood pressure, kidney function, and diabetes mellitus (p < 0.001). Although metabolic acidosis was associated with greater frailty severity in minimally adjusted models, this association was attenuated and no longer statistically significant after further adjustment for kidney function, diabetes, and inflammation. In stable kidney transplant recipients, metabolic acidosis is independently associated with increased arterial stiffness but not with frailty after accounting for key clinical confounders. Conclusions: These findings highlight metabolic acidosis as a marker of vascular vulnerability and a potential therapeutic target after kidney transplantation.

Sepsis and septic shock remain major causes of morbidity and mortality in critically ill patients. Hemodynamic management is a cornerstone of treatment, yet the optimal monitoring strategy to guide resuscitation is still debated. The progressive decline in the use of invasive techniques, such as pulmonary artery catheterization, has favored the development of less-invasive and non-invasive monitoring approaches. Recent technologies allow continuous assessment of cardiovascular function through arterial waveform analysis, non-invasive blood pressure monitoring, and predictive algorithms, while increasing attention has been directed toward the evaluation of tissue perfusion and oxygenation. This reflects the recognition that normalization of macrocirculatory variables does not necessarily ensure adequate microcirculatory perfusion in sepsis. This narrative review summarizes current evidence on less-invasive hemodynamic and tissue perfusion monitoring in sepsis and septic shock, discussing their physiological rationale and potential role within contemporary, multimodal resuscitation strategies.

Background/Objectives: Fetal lower urinary tract obstruction (LUTO) is a rare congenital anomaly that often leads to pulmonary hypoplasia and kidney dysfunction, which contribute to increased mortality. Prenatal estimation of the severity of LUTO is challenging due to the lack of specific diagnostic tools, which may guide clinical decisions. The aim of this analysis was to assess the role of fetal urinary concentrations of neutrophil gelatinase-associated lipocalin (NGAL), β2-microglobulin (B2M) and Cystatin C (CysC) in the prediction of unfavorable outcomes, such as postnatal renal dysfunction and death, among LUTO patients. Methods: A total of 38 women carrying fetuses with suspected LUTO (based on ultrasound features) were included in the study. Fetal urine was collected from the bladder of the fetus under ultrasound guidance, and measurements of NGAL, CysC and B2M were performed using an enzyme-linked immunosorbent assay. We analyzed the role of NGAL, CysC and B2M in the prediction of renal dysfunction or death within 30 days after birth. Results: Fetal urinary NGAL, CysC and B2M corrected for fetal urinary creatinine (FuCr) were significant predictors of impaired postnatal renal function or death within 30 days after birth. AUCs of ROC curves for NGAL/FuCr, CysC/FuCr and B2M/FuCr as predictors of renal dysfunction or death within 30 days after birth were: 0.793 (95% CI: 0.614-0.972, p = 0.001), 0.857 (95% CI: 0.7-1.0, p < 0.0001), 0.764 (95% CI: 0.562-0.966, p = 0.01), respectively. Among assessed biomarkers, only CysC/FuCr corrected for creatinine (p = 0.02) was associated with decreased eGFR on day 30 of postnatal life, whereas NGAL (p = 0.07) and B2M (p = 0.12) were not. AUCs of ROC curves for NGAL/FuCr, CysC/FuCr and B2M/FuCr as predictors of renal dysfunction on day 30 after birth were: 0.756 (95% CI: 0.535-0.976, p = 0.02), 0.833 (95% CI: 0.649-1.0, p = 0.0004), 0.722 (95% CI: 0.482-0.963, p = 0.07), respectively. Conclusions: Fetal urinary NGAL, CysC and B2M may constitute a promising tool in early prediction of impaired renal function and mortality in fetuses with LUTO. Accurate prediction of renal function decline after birth is crucial for proper pre- and postnatal counseling and may support prenatal intervention decision making. Further studies are required to establish the role of the studied biomarkers in the prediction of adverse outcomes.

Acute respiratory distress syndrome (ARDS) has traditionally been managed with population-based, protocolized mechanical ventilation strategies designed to limit ventilator-induced lung injury. While these approaches have improved outcomes, they fail to account for the pronounced biological, mechanical, radiological, and temporal heterogeneity that characterizes ARDS. Accumulating evidence shows that patients differ markedly in functional lung size, recruitability, chest wall mechanics, inflammatory burden, and tolerance to ventilatory stress, making uniform ventilatory targets physiologically imprecise and, at times, harmful. This narrative review examines the evolution from conventional lung-protective ventilation toward a precision-based paradigm that aligns ventilatory support with individual patient physiology. We conceptualize ARDS not as a static syndrome but as a dynamic spectrum, viewing the injured lung as a heterogeneous mechanical system susceptible to regionally amplified stress and strain. Within this framework, we discuss key principles underlying precision ventilation, including functional lung size (the "baby lung"), driving pressure, mechanical power, patient-ventilator interaction, spontaneous breathing-associated injury, and the time-dependent evolution of lung mechanics. We synthesize current evidence supporting mechanical, biological, and radiological subphenotyping as complementary strategies to individualize ventilatory management, while critically appraising their current limitations. This review also evaluates bedside tools that may operationalize precision ventilation in clinical practice, including esophageal pressure monitoring, lung ultrasound, and electrical impedance tomography, and examines the role of artificial intelligence as a clinician-directed decision-support aid rather than a prescriptive substitute for physiological reasoning. Implications for clinical trial design, ethical considerations, and future directions toward predictive and adaptive ventilation strategies are also addressed. Precision mechanical ventilation represents a shift from rigid thresholds toward proportional, physiology-guided intervention across the disease trajectory. By integrating evolving lung mechanics, ventilatory load, and patient effort over time, this approach provides a coherent framework for safer and more effective mechanical ventilation in ARDS while preserving the core principles of lung protection.

Objective: To compare tumor growth rate between patients with pituitary microadenomas who had mild to moderate prolactin elevation and symptoms leading to initiation of cabergoline therapy, and asymptomatic microadenomas without prolactin elevation managed with observation. Materials and Methods: In this retrospective cohort study, 139 patients diagnosed with pituitary microadenoma between 2019 and 2024 and with at least 12 months of clinical and radiological follow-up were included. Patients who received cabergoline therapy due to symptoms were classified as the dopamine agonist-positive [DA(+)] group, while those who did not receive treatment were classified as the dopamine agonist-negative [DA(-)] group. Tumor growth rate was calculated as the annual change (mm/year) in maximum tumor diameter on serial magnetic resonance imaging. Between-group comparisons were performed using the Mann-Whitney U test. A mixed-effects linear model was constructed to evaluate the interaction between time and treatment. Results: Of the 139 patients included in the study, 42 were in the DA(+) group and 97 were in the DA(-) group. There were no significant differences between the groups in terms of baseline age, follow-up duration, or tumor size (p > 0.05). The mean tumor growth rate was 0.67 ± 0.80 mm/year in the DA(-) group and 0.36 ± 0.38 mm/year in the DA(+) group (p = 0.0208). In the mixed-effects model analysis, the time × treatment interaction was statistically significant (β = -0.021 mm/month; p = 0.009). Patients receiving cabergoline showed a marked reduction in prolactin levels and improvement in symptoms in 78% of cases. Importantly, no tumor shrinkage was observed in either group; the primary observed effect was a reduction in growth velocity rather than true tumor regression. No serious treatment-related adverse effects were observed. Conclusions: In patients with pituitary microadenomas, cabergoline therapy was associated with a reduced tumor growth rate over time, while no true tumor regression was observed. These findings suggest that cabergoline exposure may influence longitudinal tumor growth dynamics in clinically ambiguous cases encountered in routine practice, without implying definitive tumor subtype classification.

Background/Objectives: Operator experience, the implementation of low frame rates during both fluoroscopy and digital subtraction angiography (DSA), and the use of modern angiographic systems are essential for maintaining diagnostic image quality while minimizing ionizing radiation exposure during stent-assisted endovascular treatment of intracranial aneurysms. At the study center, a low-dose protocol is employed, using the lowest available fluoroscopy frame rate (3.125 frames per second) and a nominal acquisition rate of 2 frames per second for DSA, three-dimensional (3D) rotational angiography, 2D/3D mapping, and roadmapping. Methods: A retrospective analysis was performed on 132 stent-assisted procedures conducted at a single tertiary center between 2018 and 2024. For each procedure, data were collected for dose-area product (DAP), reference air kerma (Ka,r), fluoroscopy time (FT), and the total number of DSA frames. Local diagnostic reference levels (DRLs; 75th percentile [P75]) and typical values (50th percentile [P50]) were established and compared with values reported in the literature. Results: For all patients the P75 values, representing DRLs, were 19.89 Gy·cm² for DAP, 332 mGy for Ka,r, 25 min 32 s for FT, and 354 DSA frames. The P50 values were 13.71 Gy·cm² for DAP, 219.5 mGy for Ka,r, 20 min 36 s for FT, and 277 DSA frames. Conclusions: In this single-center cohort, dose metrics for stent-assisted coil embolization were within the lower range of published values. Cross-study comparisons remain descriptive and require cautious interpretation. The proposed local DRLs may support quality assurance, dose optimization, and patient safety in similar clinical settings. Further multicenter and multi-operator studies are necessary to assess transferability and applicability beyond coil-only procedures. Limitations include the retrospective single-center design (single operator) and the lack of a contemporaneous control group and formal image-quality/outcome assessment.

Background/Objectives: Altered level of consciousness (ALC) is a common emergency department (ED) presentation with high mortality. We evaluated etiologies and early ED-course prognostic markers for mortality. Methods: We retrospectively identified adult ED visits with ALC (September 2023-August 2025) and classified etiologies using the ALC-10 framework. Patients transferred directly to other hospitals were excluded because post-transfer outcomes were unavailable; sensitivity analyses were performed. Overall mortality was ED death or in-hospital death, and ED mortality was death during the ED stay. Nested logistic models were prespecified: overall-mortality Model A included age, initial Glasgow Coma Scale (GCS), etiologic category, and ICU admission, and Model B added vasopressor use and mechanical ventilation within 1 h; ED-mortality Model A included age and initial GCS, and Model B added vasopressor use and mechanical ventilation. Results: ALC accounted for 2.85% (2194/76,957) of adult ED visits; 1932 patients were analyzed after excluding 262 transfer-outs. Systemic infection (25.8%) and metabolic causes (23.7%) were most frequent. Observed overall mortality was 23.6% (455/1932), including ED mortality of 6.4% (124/1932); model-based sensitivity analysis estimated adjusted overall mortality to be 23.2% (95% uncertainty interval, 22.9-23.7) among all ALC visits. In adjusted models, older age, lower initial GCS, and vasopressor use were associated with higher odds of both outcomes, while ICU admission and mechanical ventilation were associated with overall mortality. Model B showed improved discrimination (AUC 0.795 overall; 0.869 ED). Conclusions: These findings highlight the prognostic significance of age, initial neurologic status, and etiology. This study may assist in risk stratification and early resource allocation.