Minerva medica最新文献

Introduction: Experimental research sequentially identified reperfusion (in 1972) and conditioning (in 1986) as the two most powerful interventions for reducing acute myocardial infarct (AMI) size following acute coronary occlusion. These discoveries led to further experimental studies on optimal myocardial salvage and intensive clinical efforts to translate these interventions into the management of patients. This umbrella review of systematic reviews addresses the state of research on the effectiveness of pharmacological and interventional conditioning protocols to modulate the impact of ischemia and reperfusion in experimental animals and patients and the comparability of results in experimental animals and humans. This umbrella review documents the paradox of the experimental success of conditioning strategies in the experimental arena and equivocal clinical results of the application of the same conditioning strategies in patients.

Evidence acquisition: The review was conducted using the reporting guideline for overviews of reviews of healthcare interventions codified in the PRIOR statement (https://www.equator-network.org/reporting-guidelines/reporting-guideline-for-overviews-of-reviews-of-healthcare-interventions-development-of-the-prior-statement/).

Evidence synthesis: The results are summarized in the PRISMA format. A discussion is provided of known and unknown factors responsible for the lack of progress in identifying and implementing interventions to further reduce morbidity and mortality from ischemic heart disease, as well as a practical strategy to achieve timely reperfusion in a larger number of patients experiencing acute coronary syndrome.

Conclusions: While awaiting further research to develop a third window of cardioprotection, the most practical approach today is to reduce the morbidity and mortality from IHD is to mount a public education campaign to get the 50% of acute coronary syndrome (ACS) patients with prodromal AMI to the hospital to institute timely reperfusion therapy which has a proven to be the most effective therapy to limit the extend of myocardial damage in patients with IHD. However, the possibility has been raised that the human myocardium may have a genetically determined, primordial non-responsiveness to cardioprotective interventions that exists beyond the established recognized confounding factors. Primordial genetic factors may be particularly difficult to overcome.

Insomnia is a prevalent public health issue, characterized by dissatisfaction with the duration, continuity, and quality of sleep. It is closely associated with daytime symptoms, which are essential for diagnosing insomnia disorder. The condition is more common among women, middle-aged and older adults, and individuals with coexisting mental or physical health conditions. Evidence suggests that insomnia increases the risk of various health problems. Addressing insomnia is therefore crucial not only to enhance patients' quality of life but also to mitigate its significant health, social, and economic impacts. However, further studies are needed to evaluate the cost-effectiveness of insomnia treatments. Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for chronic insomnia in adults. When CBT-I proves ineffective or is unavailable, pharmacological treatments may be considered. Benzodiazepines (BZs) and benzodiazepine receptor agonists (BZRAs) are suitable for short-term treatment (up to 4 weeks). Among BZs, triazolam is notable for its short half-life and demonstrated efficacy in treating sleep-onset and middle-of-the-night (MOTN) insomnia, supported by robust clinical evidence. Additionally, triazolam does not impair psychomotor performance. In certain cases, longer-term use of BZs or BZRAs may be appropriate; however, this approach requires careful individual assessment of the benefits and risks. Non-nightly use of hypnotic medications may also be a viable option for patients who do not require nightly treatment. Low-dose sedating antidepressants may be considered for short-term insomnia management (off-label), while antipsychotics and antihistamines are not recommended for this purpose. Orexin receptor antagonists are an option for treating insomnia for up to three months. It is important to note that although insomnia guidelines are based on daily use as evaluated in randomized controlled trials, clinical practice may vary.

Introduction: This narrative review, based on the current literature, aims to evaluate whether or not preoperative ultrasound can effectively distinguish between uterine leiomyosarcomas (ULMS) and leiomyomas (ULM).

Evidence acquisition: By using PubMed, Scopus and WOS, an extensive literature search was conducted to identify ultrasound characteristics that specifically differentiate uterine ULMS from ULM.

Evidence synthesis: This review analyzed several ultrasound features to distinguish ULMS from ULM, including the maximum diameter of myometrial growth, the number of lesions (solitary/multiple), tissue echogenicity (homogeneous/heterogeneous), growth borders (regular/irregular), the presence of cystic regions, shadow presence, subjective color grading, and the vascular pattern of the myometrial lesion (circumferential/intralesional). Our findings suggest that in postmenopausal patients with abnormal uterine bleeding and a new or enlarging mesenchymal mass, ULMS should be suspected. Features such as irregular tumor margins, moderate-to-abundant intralesional blood flow, cystic regions, and lack of calcifications indicate a higher risk of ULMS.

Conclusions: Benign and malignant myometrial lesions should be disclosed by algorithms including ultrasound combined with clinical presentations and, if necessary, magnetic resonance imaging. This means that further prospective studies should be conducted to consolidate our findings.

Introduction: Dementia and Parkinson's disease (PD) are prevalent neurodegenerative disorders with substantial global health impacts. Emerging evidence suggests that SGLT2 inhibitors, such as dapagliflozin, may offer neuroprotective benefits. This study aims to evaluate dapagliflozin's association with risks of dementia and PD through a sub-analysis of a meta-analysis of randomized controlled trials (RCTs).

Evidence acquisition: This sub-analysis adhered to PRISMA 2020 guidelines and included RCTs from a prior meta-analysis focusing on dapagliflozin. Studies comparing dapagliflozin to placebo with reported dementia or PD outcomes were selected. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using a random-effects model. Heterogeneity was assessed using the I² statistic, and bias was evaluated with the Cochrane Risk of Bias 2 tool.

Evidence synthesis: Four RCTs met the inclusion criteria. For dementia, the pooled OR was 2.826 (95% CI: 0.264-30.229; I²=0%). For Alzheimer's-type dementia, the OR was 2.308 (95% CI: 0.232-22.928; I²=0%), while for PD, the OR was 0.533 (95% CI: 0.072-3.944; I²=0%). None of the results were statistically significant, and heterogeneity across studies was negligible.

Conclusions: This sub-analysis found no significant association between dapagliflozin and reduced risks of dementia or PD. While these results align with previous meta-analyses, further long-term RCTs are necessary to clarify dapagliflozin's neuroprotective potential and broader therapeutic applications.

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are common diseases, inducing increased morbidity and mortality when associated. In this narrative review, we report available evidence in the literature regarding the pathophysiology behind this association, its impact on prognosis, and the therapeutic management of both entities. AF and HFpEF share several pathophysiological mechanisms, most notably inflammation, electrical and structural remodeling of the left atrium with fibrosis and involvement of epicardial adipose tissue, all concurring to left atrial myopathy. AF and HFpEF furthermore favor one another, showing their intricated pathophysiology. The presence of AF in HFpEF worsens patients' prognosis, as does the presence of HFpEF in AF patients. Data on the specific management of this subgroup of patients is scarce. SGLT2 inhibitors appear as the cornerstone of HFpEF treatment, with the same benefit in AF patients. AF management however is less clear, apart for the need for anticoagulation based on the CHA2DS2-VA score. Rate control therapy and rhythm control therapy are in balance for symptom control. Overall, holistic approaches offer the most promises in these comorbid patients. AF and HFpEF partner in comorbid patients and worsen general prognosis. Their management is complex, as is their pathophysiology, and holistic strategies may be the most appropriate way to provide efficient care in these patients.

Introduction: Autoimmune hemolytic anemia (AIHA) is a heterogeneous group of diseases. While corticosteroids remain first-line therapy for the warm-antibody types (wAIHA), they are ineffective in cold agglutinin disease (CAD). During the last couple of decades, several new established or investigational treatment options have appeared. These advances have resulted in improvements of therapy, but also raised new challenges.

Evidence acquisition: This review aims at providing an update on AIHA treatment with focus on novel and investigational approaches. PubMed was searched for original research articles and reviews from 2000 through 2024. Selected case reports, published congress presentations, book chapters, and older articles were included when considered relevant.

Evidence synthesis: Pathogenetic features and diagnostic workup in AIHA are briefly outlined, and existing therapies for the respective subtypes are reviewed. The evidence for new documented therapies is described, including erythropoietin, fostamatinib, and bortezomib-based combinations in wAIHA; and complement-directed therapies in CAD. Investigational and experimental therapies are also addressed, including inhibitors of the neonatal Fc receptor, cytokine inhibitors, complement blockers, Bruton tyrosine kinase inhibitors, and plasma cell-directed approaches in wAIHA; and Bruton tyrosine kinase inhibitors, plasma-cell directed therapies, novel complement inhibitors, cytokine antagonists, and novel monoclonal antibodies in CAD.

Conclusions: Exact diagnostic workup is critical for selection of optimal therapy in AIHA. While therapy is becoming increasingly evidence-based, several unmet needs remain. The ideal therapy has not been found for wAIHA or CAD, and evidence-based options are largely lacking for the still rarer subtypes. Patients with AIHA should be considered for clinical trials.

Background: Endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) are key diagnostic tools for rectal cancer staging. ERUS is preferred for early-stage cancer, while MRI is the standard for advanced stages. However, their effectiveness in patients undergoing neoadjuvant therapy (NAT) remains debated. This study compares ERUS and MRI in rectal cancer evaluation, correlating results with final histopathological findings and analyzing a subgroup of patients who received NAT.

Methods: A retrospective study (February 2020 to February 2024) included oncology patients with rectal cancer treated electively at our Center, who had undergone both ERUS and MRI staging.

Results: Out of 172 surgical patients, 50 met inclusion criteria (42% male, average age 71.9). Surgical procedures included 36 anterior rectal resections and 14 abdominoperineal resections, with a laparoscopic approach in 84% of cases. Additionally, 74% underwent NAT. ERUS showed high sensitivity and specificity for early-stage (T1 and T2) and lymph node detection, while MRI was optimal for T3 and T4 staging. Correlation with histological findings was strong for ERUS and less so for MRI. In NAT patients, results were consistent, but MRI showed better accuracy for lymph node involvement.

Conclusions: ERUS and MRI are essential for rectal cancer diagnostics. ERUS is superior for early stages and lymph node evaluation, whereas MRI excels in advanced stages (T3 and T4). In NAT patients, ERUS remains favourable, but MRI's sensitivity and specificity improve for lymph node assessment.

This article was published in Volume 112, issue 4 of publishing year 2021, with a mistake in the text and in Table I. The corrections to the text and the correct Table I are the ones included in this erratum. Page 514, second full paragraph, line 30 should read as follows: "According to Table I, a nasal swab (rapid test) for detection of SARS-CoV-2 specific antigen was performed in 33 countries and in 46 children, respectively, in the treated and in the control groups."

A large proportion, possibly over half, of patients presenting for preoperative evaluation will be taking antihypertensive agents. The multiple classes of agents and their use in different combinations can make management decisions challenging. Poor blood pressure control and lack of evidence or conflicting evidence for certain agents can further complicate management. Appropriate antihypertensive management is important because it can have an effect on meaningful perioperative outcomes, including mortality. In this review, we discuss the factors that should be considered when making preoperative hypertension management decisions and we summarize the available evidence for the most common classes of antihypertensive agents, including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and diuretics. In addition to preoperative management, the review includes information on perioperative and postoperative blood pressure management considerations. Where possible, we provide recommendations based on the available evidence and the guidance published by expert bodis. However, due to the variety of factors that may influence management, clinical decisions for individual patients must be made on a case-by-case basis.