Postgraduate medicine最新文献

Chronic kidney disease (CKD) is a global health challenge affecting more than 850 million people worldwide. Early and accurate assessment of kidney function is crucial for timely diagnosis and management. While serum creatinine (SCr) has traditionally been the primary biomarker for estimating glomerular filtration rate (GFR), it is influenced by factors such as muscle mass, age, sex, and diet, among others, leading to potential inaccuracies. This review evaluates the biological basis, clinical performance, and limitations of cystatin C as an alternative and complementary biomarker to serum creatinine for estimating GFR in CKD. We reviewed epidemiologic, mechanistic, and clinical studies examining cystatin C metabolism, assay methodologies, and its performance in estimating GFR and predicting CKD-related outcomes. Evidence comparing creatinine-based, cystatin C - based, and combined eGFR equations was synthesized. Cystatin C, a low-molecular-weight protein produced by all nucleated cells, is less influenced by muscle mass and dietary factors than creatinine. Cystatin C based and combined creatinine - cystatin C eGFR equations demonstrate improved accuracy for detecting early CKD and more reliably predict CKD progression, cardiovascular events, and mortality. However, cystatin C levels may be affected by thyroid dysfunction, corticosteroid use, inflammation, smoking, obesity, and malignancy, requiring careful interpretation. Cystatin C provides important diagnostic and prognostic information beyond serum creatinine alone and enhances the accuracy of GFR estimation when used in combination with creatinine. Its integration into clinical practice may improve CKD detection and risk stratification, particularly in populations where creatinine-based estimates are unreliable.

Objectives: Recent therapeutic advances have improved survival for patients with relapsed or refractory follicular lymphoma (R/R FL). Given variations in treatment attributes, understanding patient preference is critical. A discrete choice experiment survey was conducted to assess treatment preferences among patients with R/R FL.

Methods: The survey was conducted from 04/2024-05/2024 among United States adults with R/R FL, recruited through online patient panels, physician referrals, and support groups. FL treatment attributes related to efficacy, safety, and convenience were selected based on targeted literature review and clinical inputs. Patient preferences were assessed using conditional logistic regression models calculating the relative importance of and willingness to trade off treatment attributes.

Results: The survey included 100 patients (median age: 61; 58.0% male), 82.0% of whom received ≥ 3 lines of therapy. All experienced ≥ 1 adverse event (AE). Patients preferred treatments with longer progression-free survival (PFS), less AE impact on quality of life (QoL), and oral administration (all p < .001). Treatment duration did not have a statistically significant impact. PFS was most important, followed by cytokine release syndrome (CRS) impact on QoL, mode of administration, rash and neurological event impact on QoL, travel time to access medication, and treatment duration. Treatment attributes in order of high to low relative importance to patients were PFS (26.8%), CRS impact on QoL (19.7%), mode of administration (15.8%), rash (14.6%) and neurological events' (14.2%) impact on QoL, and travel time to access medication (4.9%). Treatment duration (4.0%) was the least important attribute.

Conclusion: PFS had the greatest impact on treatment selection among patients with R/R FL, followed by the impact of CRS on QoL and the mode of administration. Patients were willing to trade some efficacy for improved safety and convenience, while treatment duration had minimal influence. Incorporating patient preferences may improve adherence and outcomes and warrants further evaluation.

Introduction: Extracorporeal shock wave lithotripsy (ESWL) is currently the first-line treatment for pancreatic stones larger than 5 mm. However, it remains unclear whether the presence of a preexisting pancreatic stent during ESWL influences the procedure's efficacy or complication rate. This study aims to evaluate whether the stent should be removed prior to ESWL.

Methods: All consecutive patients who underwent ESWL between March 2011 and March 2020, with a history of pancreatic stent placement within the two years preceding ESWL, were included in the study. Based on the presence or absence of an indwelling pancreatic stent during the ESWL procedure, the patients were categorized into two groups: the stent group and the non-stent group. The primary outcome assessed was the rate of spontaneous stone clearance following ESWL. The secondary outcome included number of ESWL shock waves and post-ESWL complications.

Results: A total of 704 patients were initially enrolled. After exclusions, 117 patients in the non-stent group and 200 in the stent group were included in the final analysis. The rate of spontaneous stone clearance was significantly higher in the non-stent group than in the stent group (64.1% vs. 28.5%; p < 0.001). However, no significant differences were observed between the two groups in the number of shock waves required for successful stone fragmentation (7475.0 ± 3508.7 vs. 7777.8 ± 3908.7; p = 0.478), nor in the overall incidence of post-ESWL complications (5.5% vs. 7.7%; p = 0.439).

Conclusions: The presence of a pancreatic stent is associated with reduced rates of spontaneous stone clearance but does not significantly affect the incidence of ESWL-related complications. Therefore, proactive removal of the stent prior to ESWL may be considered.

Background: Hepatic hilar tuberculosis lymphadenitis is a rare condition that often mimics other diseases, leading to diagnostic challenges due to its nonspecific clinical presentation. It can be easily mistaken for a malignant tumor, complicating the diagnostic process.

Case presentation: A 34-year-old woman was incidentally found to have a space-occupying lesion in the porta hepatis during a routine physical examination. Imaging revealed an irregular mass located posterior to the portal vein and in the head of the pancreas. Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) was performed, yielding necrotic material, multinucleated giant cells, and epithelioid cells, suggestive of tuberculosis. Acid-fast bacilli were detected on smear, confirming the diagnosis of porta hepatis tuberculosis.

Management and outcome: After the initiation of anti-tuberculosis therapy, follow-up CT scans demonstrated a reduction in lesion size with partial calcification. EUS-FNA played a crucial role in providing a timely cytological and histopathological diagnosis, enabling early treatment and avoiding unnecessary surgical interventions such as exploratory laparotomy.

Conclusion: This case underscores the utility of EUS-FNA in diagnosing rare conditions like hepatic hilar tuberculosis lymphadenitis, highlighting its value in differentiating tuberculosis from malignancy and guiding appropriate clinical management.

Objective: This study investigated whether different organ involvements in Behçet's syndrome (BS) are associated with distinct comorbidity profiles.

Materials and methods: A retrospective cohort study was conducted using records of 345 patients who met the 1990 International Study Group criteria for BS. Patients were categorized into three groups based on organ involvement: Vascular (n = 102), Mucocutaneous (n = 94), and 'Others' (n = 149). Data on comorbidities and treatments were collected, and statistical analyses were performed to compare comorbidity frequencies across the groups. Binomial logistic regression was used to examine the relationship between comorbidity profiles and involvement groups.

Results: The Mucocutaneous group had the lowest comorbidity rate at 37.2%, while the Vascular group showed the highest rate at 59.8%, with a significant increase in cardiovascular comorbidities such as coronary artery disease and stroke. No significant differences were found in Diabetes Mellitus (DM), hyperlipidemia (HL), or hypertension (HT) between groups. Coronary artery disease and stroke were categorized as 'cardiovascular disease (CVD).' Logistic regression showed that vascular involvement independently predicted CVD, even when adjusted for HT, DM, and HL.

Conclusion: Vascular involvement in BS is associated with a higher burden of cardiovascular comorbidities and serves as an independent predictor of CVD. These findings may highlight the need for tailored management strategies based on specific clinical presentations.

Objectives: To evaluate the extent of clinical concordance and phenotypic variability among pediatric FMF sibling pairs carrying identical biallelic exon 10 MEFV variants.

Methods: This cross-sectional study included 194 pediatric FMF patients from 97 families, all harboring identical biallelic pathogenic exon 10 variants. After excluding four monozygotic twin patients from two families, 190 non-twin siblings from 95 families were analyzed. Demographic information, clinical manifestations, disease severity scores (Pras, ISSF), colchicine response rates and genetic data were collected retrospectively.

Results: In 88 of 95 families, the older sibling was the index case. Older siblings had significantly longer diagnostic delays and higher Pras severity scores at diagnosis. Arthritis was more prevalent among older siblings (30% vs. 13%, p = 0.006), while other FMF symptoms were comparable. Full concordance in clinical features was observed in 41% of pairs, while colchicine response status matched in 79%. Discordance in disease severity scores and attack frequency was also noted. Monozygotic twins exhibited a high degree of clinical concordance.

Conclusion: This study shows that while main clinical features are largely concordant among siblings with identical genotypes, notable differences in disease severity scores and arthritis prevalence exist. These differences are likely attributable to diagnostic delays and age-related disease evolution rather than intrinsic phenotypic divergence.

The global increase in obesity, driven by socioeconomic development, poses significant public health challenges owing to its phenotypic heterogeneity. Individuals with obesity, according to body mass index (BMI) and metabolism health, are classified into six common subgroups: metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUHNW), metabolically healthy overweight (MHOW), metabolically unhealthy overweight (MUHOW), metabolically healthy obesity (MHO), and metabolically unhealthy obesity (MUHO). Populations with MHO exhibit high BMI but maintain normal glucose, lipid, and insulin levels. However, their long-term risks and mechanisms remain unclear. The relationship between MHO, its biomarkers, and disease risks was examined in this review, emphasizing its clinical significance. Adipose tissue dysfunction driven by chronic inflammation, oxidative stress, and adipokine imbalance underlies metabolic dysregulation. BMI remains widely used as a primary diagnostic tool; nevertheless, its limitation in differentiating MHO from MUHO highlights the importance of incorporating more precise biomarkers, including inflammatory markers, adipokines, myokines, epigenetic regulators, and other clinical indices. Individuals with MHO may initially exhibit a relatively benign metabolic profile; however, they remain at an increased risk of developing type 2 diabetes, cardiovascular diseases, and other cardiometabolic conditions. We propose risk factors for predicting MHO progression, providing critical insights for early intervention and personalized management.

Background: Scabies is a common parasitic skin disease causing intense pruritus and psychological distress. While permethrin and ivermectin are both established first-line therapies, their comparative effects on psychological outcomes and dermatology-specific quality of life remain underexplored. This study aims to compare the effects of permethrin and ivermectin on anxiety, depression, sleep quality, and dermatology-related quality of life.

Methods: This multicenter cohort study included 600 adults with confirmed scabies who were treated between February and August 2025. Of these, 292 received oral ivermectin and 308 received topical permethrin. Patients who completed a full 6-week treatment course were evaluated using the Visual Analog Scale (VAS) for pruritus, Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index (PSQI), and Skindex-29. Between- and within-group analyses were conducted, supported by multivariate linear regression, subgroup interactions, ANCOVA, and mediation analysis.

Results: Both treatments significantly improved VAS, PSQI, HADS-depression, and Skindex-29 scores (p < 0.001). However, anxiety reduction (HADS-anxiety) was greater with permethrin than ivermectin (p < 0.001), a difference that remained significant after adjusting for change in pruritus. Permethrin also showed superior outcomes in emotional quality of life (Skindex-Emotions; p = 0.022). No serious adverse events were reported.

Conclusions: While both agents are effective, permethrin may confer greater short-term psychological benefit. These findings highlight the relevance of psychobehavioral mechanisms in scabies management beyond symptom control.

Introduction: The link between 5-alpha reductase inhibitors (5-ARIs) and depression has raised concerns due to the widespread and prolonged use. Previous studies and meta-analyses reported inconsistent results without clear explanations for the heterogeneity. This meta-analysis aims to quantify the depression risk associated with 5-ARIs and evaluate how control group selection contributes to the heterogeneity of reported results.

Methods: We conducted a systematic review and meta-analysis of articles from Scopus, Embase, and MEDLINE. The search was performed from database inception to January 2025.

Results: Five longitudinal studies (n = 2,517,859 patients, effect size = 8), across a wide range of populations (US, UK, Canada, South Korea) and time periods (1992 - 2018) were included. 5-alpha-reductase inhibitor use was associated with a 31% increased risk of depression (HR 1.31, 95% CI 0.98-1.76), with high heterogeneity (I² = 95.5%, τ² = 0.0984, p < 0.0001). When stratified by comparator type, studies using non-drug controls reported a significantly elevated risk (HR 1.61, 95% CI 1.20-2.16, I² = 94.4%, τ² = 0.0635, p < 0.0001), while those using alpha-blocker comparators showed decreased risk (HR 0.89, 95% CI 0.86-0.92, I² = 0%, τ² = 0, p = 0.9711). The choice of comparator group explained the most heterogeneity across studies, while the type of 5-alpha-reductase inhibitors showed similar results.

Conclusions: The risk of depression with 5-ARI use is likely minimal. Observational data utilizing active comparators suggests a 10% reduction in risk, while randomized data from a cancer prevention trial suggests a potential risk increase of approximately 10%. Previous reports of up to 200% increased risk likely stem from inappropriate control group selection that failed to account for disease burden.