Medicine最新文献

Prolonged labor, defined as labor extending beyond 20 hours for nulliparas and 14 hours for multiparas, poses significant risks to both maternal and neonatal health. The inflammatory response plays a crucial role in the pathophysiology of prolonged labor, with neutrophils being key players in this process. Neutrophils, the most abundant leukocytes, exhibit diverse phenotypes and functions in response to prolonged labor, influencing both the onset and progression of labor through their inflammatory actions. Classical neutrophils (N1) are involved in acute inflammatory responses, aiding in tissue remodeling and labor onset, but their prolonged activation can lead to tissue damage. Regulatory neutrophils (N2), which produce anti-inflammatory cytokines, help resolve inflammation and facilitate labor progression. Low-density granulocytes and aged neutrophils, associated with chronic inflammation and impaired function respectively, contribute to labor complications. The balance among these neutrophil phenotypes is crucial for maintaining a controlled inflammatory response during labor. Therapeutic strategies targeting neutrophil recruitment, NETosis, and cytokine production hold promise for managing prolonged labor. Modulating chemokine pathways, regulating NET formation, and balancing cytokine profiles may reduce inflammation and improve labor outcomes. Further research into the mechanisms of neutrophil regulation and the development of targeted therapies is essential for mitigating the adverse effects of prolonged labor and enhancing maternal and neonatal health.

Rationale: Lumbar 5 (L5) selective nerve root block is a common treatment for lumbar 4/5 disc herniation. It is difficult to perform real-time ultrasound-guided targeted L5 nerve root block because of the deep structure of the L5/S1 intervertebral foramen and the occlusion of the sacrum and ilium. Therefore, the safe and efficient implementation of L5 nerve root block is very important for improving the clinical promotion and use of this procedure.

Patient concerns: A 43-year-old male, who presented with a 1-month history of lumbosacral and left lower limb pain.

Diagnoses: The characteristic manifestation of pain symptoms was continuous and distending-like pain, accompanied by numbness on the posterior side of the left lower limb. The pain could be exacerbated by prolonged standing, sedentary behavior, and turning over while being relieved by lying down to rest. The visual analog score was 7 triggered by innocuous stimuli, configuring a clinical picture of typical protrusion of the lumbar intervertebral disc. Physical examination: muscle tenderness, straight leg-raising test of the left lower limb was 60° (+), test of supinating and throwing out one's belly (+), and Achilles tendon reflex (-).

Interventions: The patient underwent an ultrasound-guided L5 nerve root block with a modified puncture approach technique called the "transverse process-zygapophysis separation method."

Outcomes: The patient had a successful nerve blockade characterized by significant reduction in pain after the operation.

Lesson: The innovative puncture approach method may be considered a therapeutic option in patients with chronic pain.

The timing of prophylactic antibiotic use has become a hospital's surgical quality indicator. This study aims to assess the association of hospital characteristics with rate of prophylactic antibiotic use over 1 day for clean surgery. The retrospective cohort study was conducted using open government data, and hospitals must legally disclose to Taiwan's National Health Insurance Administration (NHIA). We identified 278 hospitals that reported 9491 records of prophylactic antibiotic use over 1 day for clean surgery from the 2009 first quarter to the 2019 fourth quarter. Regression models with generalized estimating equations were estimated. Overall, the median rate of prophylactic antibiotic use over 1 day for clean surgery in hospitals was 11.1% (interquartile range: 1.9% to 30%). Multivariable analyses showed that regional (coefficient [B] = 9.45, 95% confidence interval [CI]: 6.02-12.87, P < .001) and local hospitals (B = 15.04, 95% CI: 9.61-20.47, P < .001) had higher rates of prophylactic antibiotic use more than 1 day for clean surgery than medical centers. Moreover, public (B = 4.94, 95% CI: 0.61-9.28, P = .025) and medical care corporation hospitals (B = 8.17, 95% CI: 0.85-15.49, P = .029) experienced significantly greater proportions of antibiotic use over 1 day for clean surgery than medical care foundation hospitals after adjustments. This study revealed that low-level, public, and medical care corporation hospitals had higher rates of prophylactic antibiotic use over 1 day for clean surgery. These findings may represent a quality improvement opportunity for postoperative antibiotic use.

Rationale: Thyroid eye disease (TED) is the most common orbital disorder in adults and significantly affects patient health. Orbital decompression surgery is an important treatment option. Central retinal artery occlusion (CRAO) after orbital medial wall decompression is rare in patients with TED. Therefore, the earlier the identification and treatment, the more likely it is to reduce visual impairment.

Patient concerns: This paper examines a case of CRAO occurring postoperatively in a patient who underwent medial wall orbital decompression for TED.

Diagnoses: Central retinal artery occlusion.

Interventions: During the operation, the pupil was dilated, and eye massage and peribulbal injection of atropine were performed immediately. Fundus fluorescein angiography suggested the possibility of CRAO. Intravenous methylprednisolone 1000 mg, mannitol 50 g, ginkgo biloba extract 20 mL, nimodipine 20 mg tid, cobamamide 0.5 mg tid, and oral citicoline 0.2 g tid, along with periocular injection of atropine and hyperbaric oxygen therapy were also administered.

Outcomes: Fifteen days after onset, the patient's retinal edema and retinal blood perfusion greatly improved. The patient's visual acuity recovered from counting fingers to 0.6.

Lessons: Retinal vascular obstruction is a serious threat to vision; therefore, early detection and treatment are very important.

Background: To systematically review the efficacy and safety of second-line medications for status epilepticus (SE).

Methods: Electronic searches were conducted in PubMed, Embase, and The Cochrane Library for randomized controlled trials of second-line medications for SE from inception to January 2024. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of included studies. Network meta-analysis was performed using R 4.2.2 software.

Results: A total of 23 randomized controlled trials were analyzed, examining the efficacy of 5 different treatment regimens: levetiracetam (LEV), phenytoin (PHT), fosphenytoin (FPHT), valproate (VPA), and phenobarbital (PHB). The results of the network meta-analysis indicated that the seizure control rate ranking was as follows: PHB (98.1%) > LEV (60.7%) > FPHT (40.3%) > PHT (33.0%) > VPA (17.8%). The surface under the cumulative ranking (SUCRA) values revealed that PHB had the highest ranking (SUCRA, 91.8%), followed by VPA (SUCRA, 69.3%), PHT (SUCRA, 56.1%), and FPHT (SUCRA, 5.9%) for the recurrence of seizures within 24 hours. Subgroup analysis revealed that PHB was most effective for seizure control in both pediatric and adult populations, VPA demonstrated superior efficacy in children across various indicators, LEV was deemed the safest option for children and elderly individuals, and VPA was identified as the safest choice for adult patients.

Conclusions: PHB continues to be a prominent option for managing SE, although its safety profile warrants careful consideration. Meanwhile, both VPA and LEV offer distinctive advantages in the treatment of SE, with each demonstrating commendable safety profiles.

Background: This systematic review aims to explore the effect of traditional Chinese medicine combined with chemotherapy on the clinical efficacy of breast cancer postoperative patients, providing theoretical basis for the treatment of breast cancer postoperative patients with traditional Chinese medicine.

Methods: A comprehensive search was conducted on databases such as China National Knowledge Infrastructure, Wanfang Database, VIP Database, Chinese Biomedical Literature Database, PubMed, and the Cochrane Library from their inception to August 2023 to screen RCTs comparing the effect of traditional Chinese medicine combined with chemotherapy with that of chemotherapy alone on the clinical efficacy of breast cancer postoperative patients. The included literature was systematically reviewed.

Results: A total of 22 RCTs involving 1834 breast cancer postoperative patients were finally included, with 918 patients in the traditional Chinese medicine combined with chemotherapy group (treatment group) and 916 patients in the chemotherapy alone group (control group). Meta-analysis showed that compared with the control group, therapeutical effective rate, CD3, CD4, CD4/CD8, and adverse reactions in the treatment group were all improved, and the incidence of leukopenia and thrombocytopenia after chemotherapy were all reduced, with statistically significant differences.

Conclusion: Traditional Chinese medicine combined with chemotherapy is superior to chemotherapy alone in improving the therapeutical effective rate after breast cancer surgery, reducing chemotherapy adverse reactions, and enhancing immune function.

To examine the possible causative association between Crohn disease (CD) and the T-cell surface glycoprotein CD5 and to ascertain whether sphingomyelin (SM) functions as a mediator. We conducted a two-step Mendelian randomization (MR) study to further explore the pathogenesis of Crohn and its related targets. MR study was performed on CD5 and CD using summary-level data from a genome-wide association study. Additionally, by employing a two-step MR study method, we determined that SM might mediate the causal effect of CD5 on CD. There was a favorable correlation between the surface glycoprotein CD5 on T cells and vulnerability to CD, and SM mediated the causal effect of CD5 on CD (the mediating effect accounts for 9.2%). Our study revealed that CD5 and CD are causally related, with SM mediating a small fraction of the impact (approximately 9.2%). The mediating function of SM in the link between CD5 and CD is anticipated to be realized through the regulation of immune cell transportation, apoptosis of intestinal barrier cells, and maintenance of the intestinal microenvironment.

Background: Chronic obstructive pulmonary disease (COPD) is a complex progressive disease. Some vasodilators have been reported with therapeutic potential to protect vascular function therefore may delay the progression of COPD.

Methods: We searched PubMed, Embase, Cochrane Library, Web of Science, OVID and Clinicaltrials.gov database for eligible randomized controlled trials (RCTs) published before January 1, 2024. RCTs which treatment with vasodilators to COPD patients were included. Gas-blood exchange indicators were the primary outcomes, and ventilation function and quality of life indicators were the secondary outcomes. Mean differences with 95% confidence intervals were extracted. Subgroup analysis of vasodilator category and COPD complicated with or without pulmonary hypertension (PH) were performed. The risk of bias was assessed using Cochrane risk of bias tool, and the meta-analysis was conducted.

Results: Twenty studies with a total sample size of 986 were included. The results showed that the 2 types of drugs in vasodilators included PDE-5 inhibitors could improve DLCO (MD = 6.56 [95% CI (1.74, 11.39)], P = .008) and iNO could reduce PaCO2 (MD = -0.10 [95% CI (-0.17, -0.03)], P = .006). Vasodilators could reduce PaCO2 in COPD complicated with PH (COPD-PH) (MD = -0.10 [95% CI (-0.17, -0.03)], P = .006). There were no statistically significant differences in FEV1 (MD = 0.02 [95% CI (-0.11, 0.16)], P = .74), FEV1% predicted (MD = 0.07 [95% CI (-1.90, 2.05)], P = .94), FEV1/FVC (MD = 0.70 [95% CI (-4.02, 5.42)], P = .77) and VE/VCO2 (MD = -0.17 [95% CI (-2.39, 2.05)], P = .88) levels. The total SGRQ score was significantly lower in vasodilator groups (MD = -5.53 [95% CI (-9.81, -1.24)], P = .01).

Conclusions: The therapeutic effects of vasodilators for COPD are controversial. In this meta-analysis, vasodilators have benefits in improving gas-blood exchange function and quality of life in COPD patients. However, vasodilators may have a limited capacity to improve pulmonary function.

Thoracolumbar burst fracture treatment in neurologically intact patients is controversial with many classification systems to help guide management. Thoracolumbar Injury Classification and Severity score (TLICS) provides a framework, but evidence is limited, and recommendations are primarily based on expert opinion. In this retrospective cohort study, data was reviewed for patients with thoracolumbar burst fractures at a Level-1 Trauma Center in New England from 2013 to 2018. Neurologically intact patients without subluxation/dislocation on supine computed tomography were included. Multimodal pain control and early mobilization were encouraged. Patients that failed to mobilize due to pain were treated with operative stabilization. Outcome measures include degree of kyphosis, visual analog scale pain scores, and neurological function. Thirty-one patients with thoracolumbar burst fractures with TLICS scores of 4 or 5 were identified, of which 21 were treated nonoperatively. Kyphosis at final follow-up was 26.4 degrees for the nonoperative cohort versus 13.5 degrees for the operative group (P < .001). Nonoperative patients tended towards shorter hospital lengths-of-stay (3.0 vs 7.1 days, P = .085) and lower final pain scores (2.0 vs 4.0, P = .147) compared to the operative group. Two patients (6%) developed radicular pain with mobilization, which resolved after surgical intervention. No patients experienced decline in neurologic function. A trial of mobilization for neurologically intact TLICS grade 4 and 5 thoracolumbar burst fractures is a safe and reasonable treatment option that resulted in successful nonoperative management of 21 out of 31 (68%) patients.

Childhood neurodevelopmental disorders (NDDs), including autism spectrum disorder (ASD), attention-deficit hyperactivity disorder, and Tourette syndrome, are a predominant cause of health-related disabilities in children and adolescents. Nevertheless, disease biomarkers are still limited. The aim of this study was to evaluate the potential, causal relationship between mitochondrial DNA copy number (mtDNA-CN), metabolic disorders, and childhood NDDs using the two-sample Mendelian randomization (MR) method. Genetic associations with mtDNA-CN, disorders of lipoprotein metabolism, and disorders of iron metabolism were selected as exposures, and genome-wide association data from ASD, attention-deficit hyperactivity disorder, and Tourette syndrome were utilized as outcomes. Results of the study suggested that a high degree of disordered lipoprotein metabolism related increases in ASD risk result from a decrease in mtDNA-CN (disordered lipoprotein metabolism-mtDNA: inverse variance weighting β: -0.03, 95% confidence interval: -0.05 to -0.02, P = 2.08 × 10-5; mtDNA-CN-ASD: inverse variance weighting odds ratio: 0.83, 95% confidence interval: 0.69-0.99, P = .034). The research findings implied that mtDNA-CN can mediate disorders of lipoprotein metabolism, potentially influencing the development of ASD. The potential impact of the results of this study for the prevention and treatment of childhood NDDs warrants validation in robust randomized clinical trials.