QJM: An International Journal of Medicine最新文献

Gastric cancer (GC) is a significant global health challenge, particularly in high-incidence regions like East Asia. Despite improvements in screening and treatment, the progressive nature of precancerous lesions-such as atrophic gastritis, intestinal metaplasia, and dysplasia-necessitates effective prevention strategies. This review evaluates the role of chemoprevention in GC, focusing on agents designed to target these precancerous lesions. The interventions examined include nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, antioxidants, vitamins, folic acid, bioactive compounds, traditional herbal medicines, and emerging agents like metformin. Additionally, the potential of oxygen radical scavengers, anti-inflammatory agents, and pathway-specific inhibitors is explored. While promising, the clinical effectiveness of these agents varies, and significant challenges remain in translating preclinical successes into clinical practice. Large-scale clinical trials are essential to validate these strategies and determine their role in GC prevention, particularly for high-risk populations. Integrating chemoprevention with existing GC management protocols may offer a more comprehensive approach to reducing GC incidence and improving outcomes.

Background: Contemporary stroke care is moving towards more holistic and patient-centred integrated approaches, however, there is need to develop high quality evidence for interventions that benefit patients as part of this approach.

Aim: This study aims to identify the types of integrated care management strategies that exist for people with stroke, to determine whether stroke management pathways impact patient outcomes, and to identify elements of integrated stroke care that were effective at improving outcomes.

Design: Systematic review with meta-analysis.

Methods: The review was conducted using Medline, CINAHL, Web of Science and the Cochrane Database of randomised controlled trials from January 2012 to January 2024. Studies that evaluated interventions as part of integrated care against a control or standard treatment group were included. Primary outcomes included mortality, recurrent stroke and major bleeding. Secondary outcomes included quality of life, unplanned readmission, anxiety and depression, lifestyle and cardiovascular risk factors, and adherence to intervention.

Results: In total, 99 studies were included and 63 were meta-analysed. Patients receiving integrated stroke care had significant reductions in recurrent stroke (RR 0.79, 95% CI: 0.63-1.00, P = 0.05, I  2 = 39%), significant improvements in quality of life (SMD = 0.41, 95% CI: 0.26-0.56, P < 0.00001, I  2 = 91%) and reduced incidence of depression (RR 0.95, 95% CI: 0.92-0.99, P = 0.007, I  2 = 22%). There were no significant differences in mortality or major bleeding.

Conclusion: The findings of this study showed that integrated care post-stroke is associated with better quality of life and reduced depression and recurrent stroke.

Autoimmune gastritis (AIG) is a chronic inflammatory condition characterized by immune-mediated destruction of gastric parietal cells, leading to oxyntic atrophy, achlorhydria, and hypergastrinemia. While AIG was historically linked to gastric adenocarcinoma and type I neuroendocrine tumors (NETs), recent evidence suggests the risk of adenocarcinoma in AIG is lower than previously believed, particularly in Helicobacter pylori (H. pylori)-negative patients. The increased cancer risk in AIG is mainly attributed to concurrent or past H. pylori infection. The incidence of gastric adenocarcinoma in AIG ranges from 0.12% to 0.5% per year, with cumulative risks over 10 years reported at 1%-3%. In contrast, type I NETs are more commonly associated with AIG, with an annual incidence of 0.68%-2.8% and cumulative rates as high as 15.3% over five years. Adenomatous polyps, which can progress to malignancy, have been reported in 4.6%-13.6% of AIG patients. This review examines the immune and molecular mechanisms underlying AIG's pathogenesis, positioning it as a model of immune-mediated epithelial injury with limited carcinogenic potential. AIG is associated with reparative metaplastic phenotypes, such as pseudopyloric and complete intestinal metaplasia, which contrast with the more aggressive incomplete intestinal metaplasia observed in H. pylori-induced gastritis. The reduced risk of adenocarcinoma in AIG is attributed to the absence of H. pylori, a T cell-dominated microenvironment, minimal macrophage infiltration, and protective factors such as altered gastric microbiota, epigenetic modifications, increased CD3+ intraepithelial cytotoxic T lymphocytes, and reduced interleukin-33/interleukin-13 signaling. Although AIG is linked to preneoplastic changes, its primary neoplastic risks include the development of type I NETs and adenomatous polyps, which carry a potential for malignant transformation, necessitating long-term surveillance in patients with hypergastrinemia, extensive atrophy, and associated gastric lesions. Challenges persist in distinguishing AIG from other atrophic gastritis types due to limitations in serological and histological markers, but emerging diagnostic tools, such as lymphocyte profiling and molecular assays, promise improved accuracy. This review underscores the importance of tailored surveillance and management strategies to address the distinct neoplastic risks associated with AIG, while advocating for further research into its immune landscape and molecular pathways.