Journal of Internal Medicine最新文献

Prediabetes is an intermediate state of glucose homeostasis whereby plasma glucose concentrations are above normal but below the threshold of diagnosis for diabetes. Over the last several decades, criteria for prediabetes have changed as the cut points for normal glucose concentration and diagnosis of diabetes have shifted. Global consensus does not exist for prediabetes criteria; as a result, the clinical course and risk for type 2 diabetes vary. At present, we can identify individuals with prediabetes based on three glycemic tests (hemoglobin A1c, fasting plasma glucose, and 2-h plasma glucose during an oral glucose tolerance test). The majority of individuals diagnosed with prediabetes meet only one of these criteria. Meeting one, two, or all glycemic criteria changes risk for type 2 diabetes, but this information is not widely known and does not currently guide intervention strategies for individuals with prediabetes. This review summarizes current epidemiology, prognosis, and intervention strategies for individuals diagnosed with prediabetes and suggests a call for more precise risk stratification of individuals with prediabetes as elevated (one prediabetes criterion), high risk (two prediabetes criteria), and very high risk (three prediabetes criteria). In addition, the roles of oral glucose tolerance testing and continuous glucose monitoring in the diagnostic criteria for prediabetes need reassessment. Finally, we must reframe our goals for prediabetes and prioritize intensive interventions for those at high and very high risk for type 2 diabetes.

Cushing's syndrome (CS) is a rare disorder, once exogenous causes have been excluded. However, when diagnosed, the majority of cases are adrenocorticotropic hormone (ACTH)-dependent, of which a substantial minority are due to a source outside of the pituitary, ectopic ACTH syndrome (EAS). Differentiating among pituitary-dependent CS, Cushing's disease (CD) and an ectopic source can be problematic. Because non-invasive tests in the evaluation of CS patients often lack adequate sensitivity and specificity, bilateral inferior petrosal sinus sampling (BIPSS), a minimally invasive procedure performed during the investigation of ACTH-dependent CS, can be extremely helpful. BIPSS is considered to be the gold standard for differentiating CD from the EAS. Furthermore, although such differentiation may indeed be challenging, BIPSS is itself a complex investigation, especially in recent times due to the widespread withdrawal of corticotrophin-releasing hormone and its replacement by desmopressin. We review current published data on this investigation and, in the light of this and our own experience, discuss its appropriate use in diagnostic algorithms.

In April 2023, the New York Times published an opinion piece by author and heart transplant patient, Amy Silverstein [1]. Ms. Silverstein's perspective provoked an array of responses, some of which were angry because of the perception that she lacked gratitude for the second and third chance at life she was given. However, as professionals in the transplant field, Ms. Silverstein's story resonated with us, particularly her description of what she called the “gratitude paradox” wherein solid-organ transplant patients are expected to be grateful for what they have—a new, functioning organ—and are either implicitly or explicitly discouraged from asking for more and better posttransplant treatment options [1]. While her observations were personal for us, we see parallels that are relevant for the entire healthcare community. Ms. Silverstein pointed to the conflicting emotions of her own gratitude for her two heart transplants in the wake of her terminal cancer diagnosis, a diagnosis she states likely resulted from long-term use of immunosuppression medications meant to preserve her transplanted organ, and her desire to have more life. She wasn't ungrateful in expressing that desire; she was simply being human. While the specifics of Ms. Silverstein's life are relevant to the field of transplantation, we believe the human desires she expressed should cause the entire healthcare community to pause and reflect about why we chose this calling and our inherent responsibilities.

The concept of the gratitude paradox is not new. The BBC correspondent Kate Morgan explored this issue in a 2021 piece examining the complexities of gratitude for being employed in the wake of the COVID-19 pandemic [2]. She discussed the dilemma many individuals experienced between being grateful to have a job during a time of rising unemployment and feeling underpaid, undervalued, and overburdened by employers [2]. Another, more historical example is the “separate but equal” laws, colloquially known as Jim Crow laws, that pervaded American life in the post-Civil War era through the Civil Rights movement of the 1960s. Under Jim Crow, Black Americans experienced and were expected to be grateful for (or as Davis [3] describes, “agreeable and non-challenging”), segregated conditions that proved to be anything but equal. There is a prevailing attitude that certain populations, in particular those who are vulnerable, such as patients with chronic medical conditions, racial and ethnic minority groups, or individuals from poorer socioeconomic backgrounds, should be thankful for whatever benefits of progress made in achieving a better life. They are viewed as troublemakers who lack gratitude whenever they suggest the bare minimum is not enough.

In our society, there is an expectation that disadvantaged and vulnerable populations should be grateful for having something that is one step above having nothin

At present, the dominating modality of assisted reproductive technology (ART) is in vitro fertilization (IVF). This treatment was introduced in 1978 with the birth of Louise Joy Brown in the United Kingdom [1]. The field of ART has ever since expanded, and today, more than 10 million children have been born as a result of IVF [2].

About a third of embryo transfers after IVF result in a clinical pregnancy, and a fourth in a live-born child [3]. This results in an annual increase of half a million children born after IVF as the result of 2 million annual embryo transfers. The remaining embryos are, in most cases, cryopreserved and available for future embryo transfers [4]. Use of frozen and thawed embryo transfers (FET) was previously considered to lead to fewer successful pregnancies as compared to fresh embryo transfers, but technical advances, such as innovative freezing techniques, vitrification and visual embryo selection of embryos or blastocysts, have improved the success rate of FET to a level on par with that of fresh embryo transfers [5].

The risk of venous thromboembolism (VTE), including pulmonary embolism (PE), is increased in women during pregnancy [6]. The incidence is most pronounced during the third trimester of pregnancy and in the immediate postpartum period. The mortality rate in pregnant women afflicted by VTE has been estimated to be between 0.8 and 1.5 per 100,000 pregnancies, with more than 90% of fatal VTEs being due to PE.

IVF results in a more than eightfold increase in both VTEs and PEs during the first trimester of fresh embryo transfer pregnancies [7]. There was no such increase in the incidence of VTEs and PEs after FET/thawed embryo transfer pregnancies [8]. This indicates that ovarian stimulation, with its oestrogen surge, seems to be a necessary prerequisite to trigger the increase in VTEs and PEs.

Furthermore, gestational hypertension and pre-eclampsia have been reported to increase during IVF pregnancies [9]. A recent interesting observation suggests that this could be related to the absence of a corpus luteum in some pregnancies.

Concerning cardiovascular disease associated with unsuccessful IVF treatment – the majority of embryo transfers – there are conflicting reports. One study showed an increased incidence of PE after unsuccessful IVF, but on the contrary, another study showed a lower incidence of VTE after failed ART.

Furthermore, many women will experience multiple subsequent IVF cycles due to the fact that only a quarter of the embryo transfers result in a live-born child. The cardiovascular effect of multiple subsequent IVF cycles has not yet been studied.

There has been a paucity of studies concerning the long-term effects of IVF on cardiovascular health. The heterogeneity of the few pre-existing studies precluded any final conclusions, but a