Postgraduate Medical Journal最新文献

Purpose: Transatlantic guidelines endorse quality metrics for timely reperfusion in patients with ST-elevation myocardial infarction (STEMI). Compliance in low- and middle-income countries (LMICs) is largely unknown.

Study design: We prospectively evaluated 2928 STEMI patients in Kerala, India, across 16 PCI-capable hospitals who received reperfusion with either primary percutaneous coronary intervention (PPCI) or fibrinolysis. Primary endpoint was a major adverse cardiovascular event (MACE) composite of death, non-fatal myocardial infarction, stroke or readmission for heart failure at 1-year.

Results: Among reperfused STEMI patients, 320 (10.9%) received timely reperfusion with either PPCI or fibrinolysis, 1985 (67.8%) received delayed PPCI, and 623 (21.3%) received delayed fibrinolysis. Timely reperfusion had lower unadjusted MACE rates than delayed PCI or fibrinolysis (timely reperfusion: 11.9%, delayed PPCI: 13.6%, delayed fibrinolysis: 23.9%, P < 0.001). Mortality was lowest in the timely reperfusion group (timely reperfusion: 6.3%, delayed PPCI: 7.8%, delayed fibrinolysis 18.8%, P < 0.001). After multivariate analysis, delayed fibrinolysis had a higher MACE rate (HR 1.52 95% CI 1.04-2.21) and mortality (HR 1.97, 95% CI 1.18-3.25) compared to timely reperfusion. Total ischemic time > 3 h and delayed first medical contact-to-needle time predicted MACE at 1 year.

Conclusions: Among STEMI patients in Kerala, India, only one in 10 eligible patients received timely reperfusion. Longer total ischemic times and delayed fibrinolysis were associated with 1-year MACE. Improving timely reperfusion is critical to enhancing STEMI outcomes in LMICs. What is already known on this topic Given the established link between delay to reperfusion and worse major adverse cardiac events (MACE), global efforts have concentrated on minimizing different components of the total ischemic time to improve ST-elevation myocardial infarction (STEMI) outcomes. Compliance in low- and middle-income countries (LMICs) is largely unknown. What this study adds In this cohort of STEMI patients in Kerala, India, total ischemic time and first medical contact-to-needle time correlated with long-term MACE rates, whereas other timeliness indicators did not. How this study might affect research, practice or policy Our study highlights the significant barriers to accessing STEMI care that are prevalent in LMICs despite incremental growth in the number of PCI-capable hospitals. The pre-hospital phase within total ischemic time is the most important quality improvement metric of STEMI care in LMICs, especially for patients chosen for fibrinolysis.

Purpose: The objective of this study was to elucidate the spectrum of brain natriuretic peptide (BNP) expression in hemodialysis patients with euvolemic status and investigate its prognostic significance.

Methods: Patients on chronic hemodialysis were enrolled. The normal range of BNP was measured and analyzed in patients with euvolemic status defined by systolic blood pressure and overhydration. Hemodialysis patients were stratified into groups according to BNP expression at baseline and followed up for 57 months, with all-cause mortality and cardiovascular disease-related death being assessed as primary outcomes.

Results: BNP significantly correlated with overhydration in all patients (r = 0.255, P = .004). In patients with euvolemic state, the average BNP level was 701 (±645) pg/ml, with a 95% confidence interval (CI) of 500-902 pg/ml. In patients with BNP < 902 pg/ml, systolic blood pressure significantly correlated with overhydration. Elevated BNP expression correlated with an increased risk of cardiovascular mortality (HR = 1.871, per 782 pg/ml increase, P = .008). The patients with continuously high levels of BNP showed significantly increased risk of cardiovascular disease-related death during follow-up (HR = 12.845, P = .005).

Conclusion: Predialysis measured BNP levels correlate with volume status, and the common range is from 500 to 902 pg/ml in dialysis patients with euvolemic status. Patients with upregulated BNP expression showed an increased risk of cardiovascular death. Key messages What is already known on this topic  The volume management of hemodialysis patients should be judged comprehensively by clinical manifestations and objective examinations. The parameters involved in the evaluation need to be further optimized. What this study adds  In hemodialysis patients, BNP serves as an indicator of volume status. Properly hydrated hemodialysis patients typically exhibit BNP levels ranging from 500 to 902 pg/ml, while persistent BNP elevation is associated with increased mortality. How this study might affect research, practice, or policy  In clinical practice, BNP can be routinely monitored in hemodialysis patients to provide information for volume adjustment and to identify patients with high mortality risk. The potential advantages of implementing targeted BNP management warrant further investigation through intervention studies.

Diverse trainees have different training experiences than non-diverse trainees; however, it has not been demonstrated if the number of diverse traits (DTs) (i.e. intersectionality) contributes to worse experiences. Our objective was to understand if the number of DTs a trainee has impacts their training experience. We distributed a survey to medical trainees at Mass General Brigham from 15/12/23 to 15/4/24. DTs were based on race/ethnicity, gender-identity, sexual orientation, birthplace, disability, and highest parental education. A total of 134 responses were obtained. Respondents with 1 DT were more likely to report dissatisfaction with the quality of their training compared to those with 0 DT (P = 0.03). However, this did not remain true for those with 2 or 3+ DT (P = 0.39, P = 0.59). Only respondents with 1 DT disagreed that they had similar opportunities for academic success to those of their peers (P = 0.03) and agreed that they had to work harder than others to be valued equally (P < 0.01). Respondents with 3+ DTs felt that their institution was not diverse (P < 0.01) and racist (P < 0.01) compared to respondents with zero DTs. Therefore, trainees with DTs had different training experiences than trainees with zero DTs, but the number of DTs did not consistently correlate with the quality of their experience. We believe this data is important for administrators to understand how intersectionality effects the trainee experience. Additionally, we believe this data can be used to gauge disparities in education and create an avenue to address issues, such as discrimination, microaggressions, and low retention rate of diverse applicants.

Purpose: This study aims to understand the molecular mechanisms underlying the aging process and identify potential interventions to mitigate age-related decline and diseases.

Methods: This study utilized the GSE168753 dataset to conduct comprehensive differential gene expression analysis and co-expression module analysis. Machine learning and Mendelian randomization analyses were employed to identify core aging-associated genes and potential drug targets. Molecular docking simulations and mediation analysis were also performed to explore potential compounds and mediators involved in the aging process.

Results: The analysis identified 4164 differentially expressed genes, with 1893 upregulated and 2271 downregulated genes. Co-expression analysis revealed 21 modules, including both positively and negatively correlated modules between older age and younger age groups. Further exploration identified 509 aging-related genes with distinct biological functions. Machine learning and Mendelian randomization analyses identified eight core genes associated with aging, including DPP9, GNAZ, and RELL2. Molecular docking simulations suggested resveratrol, folic acid, and ethinyl estradiol as potential compounds capable of attenuating aging through modulation of RELL2 expression. Mediation analysis indicated that eosinophil counts and neutrophil count might act as mediators in the causal relationship between genes and aging-related indicators.

Conclusion: This comprehensive study provides valuable insights into the molecular mechanisms of aging and offers important implications for the development of anti-aging therapeutics. Key Messages What is already known on this topic - Prior research outlines aging's complexity, necessitating precise molecular targets for intervention. What this study adds - This study identifies novel aging-related genes, potential drug targets, and therapeutic compounds, advancing our understanding of aging mechanisms. How this study might affect research, practice, or policy - Findings may inform targeted therapies for age-related conditions, influencing future research and clinical practices.

Introduction: Spasticity, a prevalent manifestation of various neurological conditions, significantly impacts the quality of life of patients. Research on the effects of oral drugs on spasticity has produced controversial results. Thus, the aim of this network meta-analysis was to compare the efficacy of oral drugs for improving spasticity in patients with different etiologies.

Methods: We searched four different databases from their inception to 30 November 2023. A network meta-analysis using a frequentist perspective was conducted to assess the effects of different oral drugs on spasticity, evaluated by the modified Ashworth scale.

Results: Our findings showed that, in a frequentist network meta-analysis, eperisone, diazepam, and baclofen had significantly greater spasticity, as measured by the modified Ashworth scale, than did the placebo (MD: -0.80; 95% CIs: -1.42, -0.18; MD: -0.68; 95% CIs: -1.28, -0.09; MD: -0.58; 95% CIs: -1.11, -0.06, respectively).

Conclusion: In summary, our study confirmed that eperisone, diazepam, and baclofen could be effective approaches for reducing spasticity of different etiologies and could be useful approaches for improving patient quality of life. Key messages What is already known on this topic: The impact of oral drugs, such as baclofen, gabapentin, tizanidine, and dantrolene, in the treatment of spasticity has been documented. What this study adds: This study determines which of the oral drugs aimed at treating spasticity is the most effective across different etiologies. How this study might affect research, practice, or policy: This study suggests tailored treatment strategies for spasticity based on its etiology.

"Medical deserts" are areas with low healthcare service levels, challenging the access, quality, and sustainability of care. This qualitative narrative review examines how artificial intelligence (AI), particularly large language models (LLMs), can address these challenges by integrating with e-Health and the Internet of Medical Things to enhance services in under-resourced areas. It explores AI-driven telehealth platforms that overcome language and cultural barriers, increasing accessibility. The utility of LLMs in providing diagnostic assistance where specialist deficits exist is highlighted, demonstrating AI's role in supplementing medical expertise and improving outcomes. Additionally, the development of AI chatbots offers preliminary medical advice, serving as initial contact points in remote areas. The review also discusses AI's role in enhancing medical education and training, supporting the professional development of healthcare workers in these regions. It assesses AI's strategic use in data analysis for effective resource allocation, identifying healthcare provision gaps. AI, especially LLMs, is seen as a promising solution for bridging healthcare gaps in "medical deserts," improving service accessibility, quality, and distribution. However, continued research and development are essential to fully realize AI's potential in addressing the challenges of medical deserts.

Background: Our objective in this study is to determine the atypical clinical presentations of cutaneous leishmaniasis (CL) patients diagnosed in Şanlıurfa province.

Methods: This retrospective study included 213 patients with atypical clinical presentations among 1751 patients diagnosed with CL between October 2019 and August 2022 in Şanlıurfa Oriental Boil Diagnosis and Treatment Center located in an endemic region for CL.

Results: We found the prevalence of atypical CL to be 12.1%. The most common atypical lesions were lupoid 21 (9.8%), erysipeloid 16 (7.5%), impetiginous 16 (7.5%), recidivan 15 (7%), eczematous 15 (7%), ecthyma-like 13 (6.1%), pyoderma gangrenous-like 12 (5.6%), and sporotrichoid 12 (5.6%). Other lesions with atypical clinical presentations: chalazion-like, verrucous, dental sinus-like, psoriasiform, zosteriform, lymphoma-like, juvenile xanthogranuloma-like, volcano-like, paronychial, basal cell carcinoma-like, squamous cell carcinoma-like, herpes labialis-like, keratoacanthoma-like, chancriform, annular, lichenoid, mastocitoma-like, keloidal, epidermoid cyst-like, kaposi sarcoma-like, scar leishmaniasis, granulomatous cheilitis-like, mycetoma-like, molluscum contagiosum-like, discoid lupus erythematosus-like, and dermatofibroma-like.

Conclusions: In addition to the atypical clinical presentations previously reported, we also defined dermatofibroma-like, Kaposi sarcoma-like, dental sinus-like, juvenile xanthogranuloma-like, mastocytoma-like, and epidermoid cyst-like. It should be kept in mind that CL can clinically mimic many infectious, inflammatory, and neoplastic diseases, which should be considered in the differential diagnosis of long-term non-healing lesions, especially in endemic areas. Key message What is already known on this subject:  CL is known as the great imitator disease in dermatology. What this study adds:  In addition to the atypical clinical presentations previously reported, we also defined dermatofibroma-like, Kaposi sarcoma-like, dental sinus-like, juvenile xanthogranuloma-like, mastocytoma-like, and epidermoid cyst-like. How this study might affect research, practice, or policy:  CL can clinically mimic many infectious, inflammatory and neoplastic diseases, which should be considered in the differential diagnosis of long-term non-healing lesions, especially in endemic areas.