Postgraduate medicine最新文献

Adult-onset Still's disease (AoSD) is a rare systemic autoinflammatory disorder of unknown etiology that affects young adults. Here, we report two cases of delayed AoSD diagnosis, which was initially diagnosed as tuberculous arthritis and systemic lupus erythematosus (SLE) before referral. In the first case, tuberculous arthritis treatment was commenced based on positive interferon-gamma release assay results, whereas in the second case, SLE was diagnosed based on clinical symptoms and positive antinuclear antibody results. There was no clinical improvement after treatment based on the initial diagnosis, patient referral, or diagnostic elaboration. After further evaluation, the clinical and laboratory features were found to be appropriate for the diagnosis of AoSD. Both patients had anemia, fever, arthritis, and high ferritin levels and were treated with high-dose methylprednisolone followed by methotrexate; clinical improvement was observed, and the ferritin levels reduced.

Objectives: The triglyceride-glucose (TyG) index is a novel diagnostic marker for various metabolic and cardiovascular diseases. However, little is known about the association of the TyG index with plasma atherogenicity, especially with its latent forms. The aim of this study was to assess the potential of the use of the TyG index as a marker of atherogenic risk.

Methods: A total of 202 men with normolipidaemia, aged 20-60 years, were enrolled in this study. Fasting biochemical parameters were measured. The TyG index was calculated as ln[triglyceride(mg/dL)×glucose(mg/dL)]/2. The diagnostic ability of the TyG index for detecting atherogenic risk was tested by receiver operating characteristic (ROC) curve analysis.

Results: A substantial portion of normolipidaemic men had deviations from the reference values for the indices calculated using apolipoproteins. Unfavorable values for the apolipoprotein (apo) B/apoA-I ratio, low-density lipoprotein cholesterol/apoB (LDL-C/apoB) ratio, and the atherogenic index (ATH index) were observed in 32.7%, 31.7%, and 14.4% of men, respectively. The results of ROC curve analysis showed that the TyG index had good diagnostic ability for identifying unfavorable apolipoprotein indices in normolipidaemic men.

Conclusions: Thus, the TyG index can be a valuable additional marker for assessing latent atherogenic risk; it can provide useful information for the diagnosis and treatment of early atherosclerosis.

Objective: To perform a comparative analysis of the three-level triage protocol conducted by triage nurses and emergency medicine doctors with the use of ChatGPT, Gemini, and Pi, which are recognized artificial intelligence (AI) models widely used in the daily life.

Materials and methods: The study was prospectively conducted with patients presenting to the emergency department of a tertiary care hospital from 1 April 2024, to 7 April 2024. Among the patients who presented to the emergency department over this period, data pertaining to their primary complaints, arterial blood pressure values, heart rates, peripheral oxygen saturation values measured by pulse oximetry, body temperature values, age, and gender characteristics were analyzed. The triage categories determined by triage nurses, the abovementioned AI chatbots, and emergency medicine doctors were compared.

Results: The study included 500 patients, of whom 23.8% were categorized identically by all triage evaluators. Compared to the triage conducted by emergency medicine doctors, triage nurses overtriaged 6.4% of the patients and undertriaged 3.1% of the yellow-coded patients and 3.4% of the red-coded patients. Of the AI chatbots, ChatGPT exhibited the closest triage approximation to that of emergency medicine doctors; however, its undertriage rates were 26.5% for yellow-coded patients and 42.6% for red-coded patients.

Conclusion: The undertriage rates observed in AI models were considerably high. Hence, it does not yet seem appropriate to solely rely on the specified AI models for triage purposes in the emergency department.

Chronic kidney disease (CKD) is a growing public health concern, affecting at least 1 in 7 adults in the United States, and accounting for a large proportion of healthcare spending. The risk of mortality rises steeply with declining kidney function, mostly due to cardiovascular-related deaths. Since CKD is asymptomatic in the early stages, diagnosis is sometimes delayed. However, early diagnosis is important for timely initiation of interventions to reduce disease progression, and to avoid the need for hospitalizations, dialysis, or kidney transplantation. This review focuses on the impact of sodium glucose transporter 2 inhibitors (SGLT2i) on CKD based on mechanistic and clinical trial evidence. These agents affect the kidneys through changes in sodium transport and metabolic factors that interfere with the primary pathological mechanisms shared by most kidney diseases. Following clinical trials of SGLT2i in patients with type 2 diabetes which demonstrated reductions in the risk of major adverse CV events, death, and hospitalizations for heart failure (HHF), and in patients with heart failure (HF) with and without diabetes which showed reductions in death and HHF, recent trials in patients with CKD have provided overwhelming support for the use of SGLT2i as foundational therapy across a broad spectrum of patients with CKD, regardless of diabetes status, primary kidney disease (except polycystic kidney disease), or kidney function. While clinical trials in CKD generally recruit patients with a high risk of events, patients at lower risk could also benefit from SGLT2i in terms of reduction of CKD progression, HF, and death, as well as other beneficial effects including reductions in blood sugar, body weight, and blood pressure.

Objectives: This study aimed to investigate the nephroprotective effect of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in elderly patients with type 2 diabetes mellitus (T2DM) and hypertension based on real-world clinical data. The study aimed to provide a theoretical basis for evidence-based pharmacological treatment of chronic kidney disease in this population.

Methods: The 'Health Cloud' platform of the Shanghai Municipal Health Commission was employed to identify and screen elderly patients with T2DM and hypertension. The propensity score matching cohort was further constructed to estimate the effect of SGLT2i on the risk of rapid decline in renal function (∆eGFR≤-5 mL/min/1.73 m² or ∆eGFR%≤-5%). Multiple sensitivity analyses were conducted to assess the robustness of the results.

Results: After propensity score matching, no significant differences of covariates were identified between the SGLT2i and non-SGLT2i groups. The results of multivariate logistic models demonstrated a consistent and inverse correlation between SGLT2i use and the risk of rapid eGFR decline, whether defined as ∆eGFR≤-5 mL/min/1.73 m² (OR = 0.60, 95% CI:0.38-0.96) or ∆eGFR%≤-5% (OR = 0.57, 95% CI:0.37-0.89). In the stratification of renin-angiotensin system inhibitor (RASi) treatment, SGLT2i was associated with a lower risk of rapid eGFR decline in the RASi group (all ORs < 1, p < 0.05), with no interaction between SGLT2i and RASi (all P for interaction > 0.05) detected.

Conclusions: SGLT2i significantly reduced the risk of rapid eGFR decline in elderly patients with T2DM and hypertension, but the synergistic effect with RASi remains unclear.

Objectives: This randomized, double-blind, placebo-controlled clinical trial aimed to prospectively examine the effect of pentoxifylline (PTX) on hypoxia-inducible factor-2 alpha (HIF-2α) and its role in controlling anemia in hemodialysis (HD) patients.

Methods: Eighty patients on HD were randomized to receive 400 mg of PTX or placebo twice daily for 6 months. The hemoglobin (Hb) and other hematologic parameters, the weekly erythropoiesis-stimulating agents (ESAs), and the ESA resistance index (ERI) were assessed monthly during the study. The HIF-2α, transforming growth factor-β1 (TGF-β1), and high-sensitivity C-reactive protein (hs.CRP) were measured before and after the intervention.

Results: In the pentoxifylline group, an appreciable increase in Hb from 9.7 (9.3, 10.3) g/dl to 10.5 (9.3, 11.4) g/dl and hematocrit (Hct) from 31.3 (29.6, 32.4)% to 33.2 (29.4, 35.9)% was observed after one month of PTX administration, and this effect was maintained over the study time (p < 0.001). This was along with a decrease in the ESA doses required from 8000 (8000, 11500) IU/wk to 4000 (2000, 8000) IU/wk (p < 0.001), and an improvement in the ERI from 11.6 (8.07, 16.97) IU/kg/wk/g/dl to 5.79 (2.01, 10.09) IU/kg/wk/g/dl (p < 0.001). Additionally, the HIF-2α increased significantly at the end of the intervention in patients who received PTX from 3245.35 (2886.8, 4691.56) pg/ml to 7208.75 (5382, 9182.7) pg/ml, while TGF-β1 and hs.CRP decreased significantly from 657.78 (539.78, 1146.62) pg/ml and 88.08 (39.93, 100.4) mg/l to 329.94 (228.67, 793.18) pg/ml and 48.65 (34.44, 84.61) mg/l, respectively. The percent changes in HIF-2α, TGF-β1, and hs.CRP levels in the pentoxifylline group were also statistically significant in comparison with the placebo group.

Conclusions: PTX could be a promising agent for correcting anemia in HD patients via increasing HIF-2α levels.

Clinical trial registration: Clinicaltrials.gov, February 2023, registry number: NCT05708248.

Calcific aortic valve disease (CAVD), a nonrheumatic stenosis of the trileaflet aortic valve, is a complex, multifaceted cardiovascular condition involving a widespread inflammatory process and an analogous atheromatous process affecting the arteries. It is currently the most encountered valvular abnormality in cardiology. Although distinctive abnormal mechanical forces are at the core propelling a responsive mechanosensitive feedback cascade, implicated in both initiation and perpetuation of CAVD; we propose a conundrum of metabolic abnormalities including hypertension, elevated fasting blood sugar, decreased high-density lipoprotein, hypertriglyceridemia, and abdominal obesity as perpetuators of this process. Furthermore, we suggest CAVD as a cardio metabolic disorder. New perspectives as well as which pathways we believe are critically involved and ideas for early intervention are discussed.

Background: Juvenile idiopathic arthritis (JIA) is a common chronic rheumatic disease in children, requiring careful management to reduce both short- and long-term morbidity. In this study, our objective was to assess the clinical features of patients diagnosed with JIA who received intra-articular corticosteroid injections (IACI).

Methods: In this retrospective study, we evaluated the clinical and laboratory characteristics of 225 JIA patients monitored from January 2012 to October 2023 at a tertiary care center. We focused on patients who underwent intra-articular corticosteroid injections (IACI) as part of their treatment. Triamcinolone hexacetonide (TH) was used due to its demonstrated safety and efficacy.

Results: Our analysis revealed that IACI, particularly utilizing TH, was a widely employed and effective adjunct therapy, contributing to rapid symptom relief and local disease control. Patients receiving IACI exhibited earlier symptom onset, younger age at diagnosis, longer follow-up durations, and higher cumulative treatment burden (p < 0.001, p < 0.001, p < 0.01, p < 0.001 respectively). Despite inconclusive acute-phase reactants, a higher frequency of ANA positivity and elevated initial lymphocyte counts were associated with increased IACI use (p < 0.001, p < 0.001 respectively). Importantly, on a joint basis, a high percentage of arthritis remission following IACI underscores its efficacy and favorable safety profile.

Conclusions: Notably, the high percentage of arthritis remission achieved with intra-articular corticosteroid injections (IACI) on a joint-specific basis highlights its efficacy and favorable safety profile. A lymphocyte count exceeding 5000/mm³ at the time of diagnosis may serve as an early indicator for considering intra-articular steroid administration. These findings emphasize the need for nuanced and individualized treatment strategies in JIA management to optimize outcomes for affected children.

Objectives: The objective of this study was to assess the risk of seizures in Giant Cell Arteritis (GCA) patients in a large cohort of Israeli subjects, in comparison to matched controls.

Methods: Patients diagnosed with GCA between 2002 and 2017 were included. Controls were matched based on sex, age, socioeconomic status, country of birth, diabetes mellitus, and hypertension in a 4:1 ratio. Patients with seizure records prior to the study period were excluded. Hazard ratios for seizures was obtained by cox regression models.

Results: The study cohort was composed by 8,103 GCA patients and 32,412 matched controls. The GCA group included 5,535 women (68%), 2,644 patients born in Israel (33%), and 2,888 patients with low socioeconomic status (36%). The median age of this group was 71. During the followed cumulative person-years of 54,641 and 222,537 in the GCA and control group, respectively, 15.92 cases per 10,000 person-years was found in the GCA group, compared to 9.62 per 10,000 person-years in the controls. GCA was associated with seizures in the unadjusted (HR = 1.66, 95% CI [1.29 to 2.13]) and adjusted (HR = 1.67, 95% CI [1.3 to 2.14]) models. GCA was also associated with seizures after controlling for strokes (HR = 1.55, 95% CI [1.16 to 2.07]).

Conclusion: According to this study, individuals with GCA are at a higher risk of developing seizures when compared to the general population. This increased risk is independent of their predisposition for stroke. One proposed mechanism is that the GCA pro-inflammatory state may decrease the neuronal threshold for depolarization.