Annual review of medicine最新文献

Chronic hypertension and preeclampsia spectrum disorders in pregnancy are important contributors to long-term maternal morbidity and mortality. Due to physiologic changes during pregnancy and the postpartum period, blood pressure expectations differ between primary care providers and obstetricians. The goal of this article is to describe the pathophysiology and definitions of hypertension in the obstetric context and review current evidence for management during pregnancy and the postpartum period. Longitudinal follow-up with a primary care provider after delivery is crucial for long-term cardiovascular risk reduction in hypertensive patients.

CD70 is an emerging target for anticancer therapies. It is an ideal antigen target given its limited expression in normal physiologic tissues and propensity to be aberrantly expressed in a variety of malignancies, thus limiting off-target toxicities. It is also heavily involved in immune homeostasis, and disruption of this pathway can help overcome tumor-related immune cell exhaustion. Recent phase I/II trials using cellular therapies targeting CD70, such as chimeric antigen receptor-T cells, have shown promising effectiveness and safety in treating relapsed or refractory renal cell carcinoma. Noncellular therapies targeting CD70, such as antibody-drug conjugates, monoclonal antibodies, radionuclides, and cytokines, are currently under investigation, with early data showing encouraging results as well. Efforts are already underway to further improve and optimize CD70-based therapies.

Hepatorenal syndrome-acute kidney injury (HRS-AKI) occurs in the setting of advanced chronic liver disease, portal hypertension, and ascites. HRS-AKI is found in ∼20% of patients presenting to the hospital with AKI, but it may coexist with other causes of AKI and/or with preexisting chronic kidney disease, thereby making the diagnosis challenging. Novel biomarkers such as urinary neutrophil gelatinase-associated lipocalin may be useful. While HRS-AKI is a functional form of AKI related to circulatory and neurohormonal dysfunction, there is increasing recognition of the importance of systemic inflammation and the renal microenvironment. Early diagnosis and initiation of HRS-AKI-specific treatment can improve outcomes. The mainstay of therapy is a vasoconstrictor (terlipressin or norepinephrine) combined with albumin, which achieves resolution of HRS in 40-50% of cases. Liver transplantation is the only option for patients failing to respond to medical therapies.

Despite rapid advances in the field of HIV prevention and treatment, unacceptably high global HIV incidence rates highlight the ongoing need for effective HIV prevention interventions for populations at risk for HIV acquisition. This article provides an updated review of the current data surrounding HIV prevention strategies, including treatment as prevention (TasP), preexposure prophylaxis (PrEP), and postexposure prophylaxis (PEP), as well as advances in sexually transmitted infection biomedical prevention. This review provides an overview of the multiple PrEP modalities that are available globally, such as oral PrEP, injectable cabotegravir, and the dapivirine vaginal ring, and describes their respective clinical trials, efficacies, and regulatory approvals. We also discuss ongoing research into novel PrEP agents, such as broadly neutralizing antibodies, and efforts toward HIV vaccine development.

In the past decade, adding mechanical thrombectomy (MT) of intracranial arterial occlusions to intravenous (IV) thrombolysis has revolutionized the treatment of acute ischemic stroke (AIS) by expanding the therapeutic window to 24 h. Treatment decisions require establishing a high probability of AIS; confirming time since last known well (LKW); assessing severity of the neurological deficit; determining any contraindications to IV thrombolysis; and performing neuroimaging, usually noncontrast computed tomography (NCCT), to exclude intracerebral hemorrhage. If time since LKW is less than 4.5 h, patients with disabling stroke without contraindications can proceed immediately to IV thrombolysis while the decision about MT is under way. For some patients, the MT decision can be made on the basis of clinical assessment, NCCT, and CT angiography showing a large vessel occlusion. Others may require additional neuroimaging. Patients who are not candidates for IV thrombolysis within 4.5 h or MT should be immediately evaluated for eligibility for extended-window IV thrombolysis or early antiplatelet treatment.

RASopathies are a group of clinically overlapping autosomal dominant disorders caused primarily by mutations in genes that reside along the canonical Ras-mitogen-activated protein kinase signaling cascade. Though individually rare, collectively, these disorders constitute one of the largest families of congenital disorders worldwide, particularly for infantile hypertrophic cardiomyopathy. Significantly, despite almost five decades of RASopathy research, therapeutic options remain limited and focused primarily on treating symptoms rather than disease etiology. Targeting the genes causal to these disorders, and the nodal pathways critical for their regulation, however, has been challenging. In this review, we highlight these challenges, particularly with respect to congenital heart defects and cardiac diseases and discuss limitations and future directions for approaches to new therapeutic strategies.

The endoscopic evaluation and management of small intestinal diseases continue to evolve and expand. The advent of small bowel wireless capsule endoscopy and deep enteroscopy with either a double- or single-balloon enteroscope now allows complete endoscopic visualization of the entire small intestine and enables access for endoscopic interventions such as biopsies or hemostasis for most of the small bowel. New endoscopic techniques are available to treat proximal malignant small bowel obstruction, including intraluminal stents and endoscopic gastrojejunal stents. Emerging technologies also aim to improve weight loss and diabetes management via small bowel endoscopic interventions.

Living-donor kidney transplantation is the preferred treatment for kidney failure. In the United States, rates of living kidney donation have been stagnant, which is partly related to concerns over medical and financial risks. Recent research has better characterized the risks of living kidney donation, although the field is limited by a lack of robust registries. Available evidence supports small increases in the risks of end-stage kidney disease and hypertensive disorders of pregnancy in living donors. For most donors, the 15-year risk of kidney failure is less than 1%, but for certain populations this risk may be higher. New tools such as genetic kidney disease panels may assist with risk stratification. Living kidney donors generally have similar or improved psychosocial health following donation compared to prior to donation and nondonor experience. Postdonation care allows for preventative care measures to mitigate risk as well as ongoing surveillance of donor outcomes. Continuing efforts to capture and report outcomes of living donation are necessary to safely expand living donation worldwide.

This review explores the evolving landscape of treatments for hypercortisolism, highlighting both established and emerging therapies. Although surgery remains the cornerstone of management, medical therapies play a crucial and expanding role, especially in cases of persistent, recurrent, or severe hypercortisolism. We discuss the effectiveness and limitations of steroidogenesis inhibitors, pituitary-directed drugs, glucocorticoid receptor antagonists, and experimental drugs targeting novel molecular pathways that have been implicated in the pathogenesis of hypercortisolism. Despite advancements, significant unmet needs persist, underscoring the importance of personalized treatment approaches and the development of targeted therapies. Ongoing and future clinical trials are crucial for validating the safety and efficacy of these innovative treatments in Cushing disease management.

In this review, we describe how the management of coronary artery disease (CAD) has become increasingly complex due to the rapid evolution of pharmacotherapy and procedural techniques. The expanding array of treatment options has driven researchers to investigate the optimal combination of therapies; while the findings offer invaluable insights, the sheer volume and occasional contradictions can foster confusion. Given the diverse spectrum of CAD and its manifestations, a tailored treatment decision is critical for each patient. We hope to demonstrate that by integrating the key messages from clinical trials and prioritizing patient comprehension and preference, healthcare providers can guide their patients toward appropriate treatment options, ultimately leading to enhanced care.