Postgraduate medicine最新文献

The high morbidity of obesity and depression pose significant public health concerns, with the prevalence of obesity doubling in the US between 1990 and 2022 and patients frequently presenting with both. Untreated obesity and depression can greatly impact patient health and well-being, as both obesity and depression are associated with a number of comorbidities including sleep apnea, type 2 diabetes mellitus, metabolic syndrome, metabolic dysfunction-associated steatotic liver disease, and cardiovascular disease. This narrative review aims to provide a comprehensive and current overview of the overlapping etiologies between obesity and depression as well as the available treatment options that may be recommended by primary care professionals to treat these patients with concomitant obesity and depression. With the considerable overlap in the population of patients with obesity and depression, as well as the overlap in the neurobiological, hormonal, and inflammatory pathways underlying both diseases, primary care professionals should consider screening patients presenting with obesity for depression. Holistic treatment options, including lifestyle and behavioral modifications, and pharmacotherapy for both depression and obesity and bariatric surgery for obesity are critical to manage both conditions simultaneously. Therefore, due to the overlapping neurobiological pathways and mechanisms responsible for the incidence and progression of both obesity and depression, a holistic treatment plan including strategies with efficacy for both conditions and any additional comorbidities may improve the clinical approach for patients with concomitant obesity and depression.

Background: Rheumatic mitral stenosis continues to be a significant public health issue in developing countries. Advances in echocardiography have made it possible to non-invasively assess atrial physiomechanics. In our study, we aimed to evaluate the changes in left and right atrial phasic functions in patients with have mitral stenosis and to investigate the relationship of these changes with clinical signs, symptoms, and intervention decisions.

Methods: Patients with rheumatic mitral stenosis who did not have comorbidities affecting cardiac function were included in this single-center, prospective study. The study population consisted of 122 subjects: 30 healthy controls with no chronic diseases and normal cardiac function confirmed by clinical and echocardiographic evaluations, 31 patients with moderate mitral stenosis, 31 patients with severe mitral stenosis and 30 patients with severe mitral stenosis with valvular atrial fibrillation. In addition to conventional echocardiographic parameters, biventricular deformation analyses were assessed using 2D-STE. Right and left atrial phasic functions were evaluated using both 2D and 3D-STE analysis and compared with clinical findings.

Results: In the patient group with severe mitral stenosis in sinus rhythm, the contractile left atrial strain values were significantly higher. The left atrial peak longitudinal (reservoir) strain values were found to be significantly lowest in the group with severe mitral stenosis accompanied by atrial fibrillation. Similarly, in the group with severe mitral stenosis accompanied by atrial fibrillation, the right atrial phasic strain values were significantly lower in both 2D and 3D measurements.

Conclusion: Mitral stenosis, the increased left atrial afterload in patients with sinus rhythm is compensated by an increase in contractile function. However, this compensatory increase is insufficient to preserve left atrial reservoir function. Patients with mitral stenosis who develop atrial fibrillation lack the compensatory contractile function, and this deficiency underlies the increased clinical deterioration associated with the development of atrial fibrillation.

Bacteremia due to Moraxella Catarrhalis is rare. An 85-year-old Japanese woman had productive cough, dyspnea, and fever. She had type 2 diabetes mellitus and chronic heart failure. Infiltration shown on chest radiography could be explained by heart failure or pneumonia. Initial blood culture yielded Gram-negative cocci, identified as M. catarrhalis. We therefore diagnosed cardiogenic pulmonary edema and M. catarrhalis pneumonia. M. catarrhalis has a high prevalence of β-lactamase production, so treatment comprised ampicillin/sulbactam. The clinical outcomes were favorable. Our case shows the importance of consideration of M. catarrhalis when patients with heart failure have pneumonia and the importance of blood culture for such patients.

Venous thromboembolism (VTE), consisting of both deep vein thrombosis (DVT) and pulmonary embolism (PE), is an extremely common condition both in the United States and worldwide. Not only is the diagnosis associated with significant morbidity and mortality for patients but it also imposes a deleterious financial burden on the US healthcare system. Diagnosis may be challenging due to variability in clinical presentation and requires a sequential workup including assessment of clinical pretest probability for VTE, D-dimer testing, and imaging. Following diagnosis, proper risk stratification is necessary to determine the appropriate treatment as well as the need for inpatient care. Elucidation of underlying major or minor risk factors at the time of diagnosis is essential as the presence of which may influence the duration of therapy. First-line treatment for most patients is anticoagulation with a direct oral anticoagulant (DOAC) for a minimum of 3-6 months. In multiple clinical trials, DOACs have proven to be non-inferior to vitamin K antagonists for the treatment of VTE with a lower risk of bleeding. Special consideration should be taken in the choice of agent and duration of treatment for patients who have underlying thrombophilias or malignancy and who are pregnant.

Background: Aspirin is largely used for cardiovascular prevention. While its adverse effect on bleeding is well-documented, the prevalence of anemia remains uncertain. We conducted a meta-analysis on how low-dose aspirin affects hemoglobin and other hematologic parameters in the elderly.

Methods: We systematically searched PubMed, Embase, and Cochrane for studies comparing the hematological parameters and the prevalence of anemia between low-dose aspirin (≤325 mg) and non-aspirin users in individuals aged older than 60 years. We pooled mean differences (MD) for continuous outcomes and odds ratio (OR) for binary outcomes, with 95% confidence intervals (CI), under a random-effects model for both.

Results: Seven studies were included, including three randomized controlled trials (RCTs), totaling 19,792 participants. Among them, 9,771 (49.3%) were treated with aspirin; 55.4% were women and 44% had a history of smoking. There was no significant difference in anemia prevalence (OR 0.85; 95% CI 0.52-1.38; p = 0.50). Mean Corpuscular Hemoglobin (MD 0.06 pg; 95% CI -0.37 to 0.49; p = 0.79), Mean Corpuscular Volume (MD -0.31 fl; 95% CI -1.17 to 0.56; p = 0.49), and hemoglobin concentration (MD -0.02 g/dL; 95% CI -0.26 to 0.21; p = 0.85) between the two groups. However, hemoglobin decline from baseline was higher in aspirin users (MD -0.11 g/dL; 95% CI -0.17 to -0.05; p = 0.0002; I² = 0%).

Discussion: Our study employs rigorous methodology and a substantial patient cohort, marking the first quantitative meta-analysis in the past decade. Limitations include diverse study designs, short follow-up durations, gender-specific anemia criteria, and insufficient ferritin and iron levels data. Nonetheless, our findings suggest that while low-dose aspirin does not increase anemia prevalence, it is associated with declining hemoglobin levels over time.

Background: Fibrinopurulent thorax is a rare condition that can lead to respiratory failure. Fibroblastic decortication surgery has been shown to be an effective treatment for chronic empyema in previous studies. However, there is limited evidence supporting surgical intervention for fibrinopurulent thorax in cases of respiratory failure.

Case description: We report a case of a male patient with a fibrinopurulent thorax and acute respiratory failure. The patient required invasive mechanical ventilation but showed no improvement, necessitating surgical intervention for empyema drainage. DNA gene sequencing technology was employed to diagnose the infection etiology, which facilitated the adjustment of antibiotics. This approach ultimately led to the patient's improvement and liberation from the ventilator.

Conclusion: This case demonstrates the efficacy of surgical treatment for fibrinopurulent thorax with respiratory failure, a scenario not previously documented in literature. Successful treatments for pneumonia and chronic empyema in the context of respiratory failure have provided both inspiration and validation for this approach. The findings of this case highlight the potential of surgical intervention as a new treatment option for clinical practice. However, as this is a single case report, further research is necessary to validate the efficacy and safety of this treatment method.

Objective: The objective of this study is to examine the potential of specific parameters in determining renal involvement in adult patients diagnosed with Immunoglobulin A vasculitis (IgAV).

Methods: The patients' records with IgAV meeting the EULAR/PRINTO/PRES classification criteria who were diagnosed between January 2017 and January 2022 were retrospectively reviewed. The Birmingham Vasculitis Activity Score (BVAS) version 3 was used to assess initial disease activity. A comparison was conducted between the data of patients with and without renal involvement. To investigate factors associated with renal involvement, the significant parameters were used to develop a forward stepwise multivariate regression model. Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the predictive ability of significant parameters for renal involvement.

Results: The study included 85 patients, of whom 22 (25.9%) had renal involvement. Patients with renal involvement had a median age of 60.5 years and a median follow-up of 56.3 months. The median BVAS and ferritin/albumin ratio (FAR) values were significantly higher in patients with renal involvement (p < 0.001). Multivariate regression analysis identified initial BVAS and FAR values as factors associated with renal involvement. ROC analysis demonstrated that the initial BVAS and FAR values were associated with renal involvement, with AUCs of 0.882 and 0.817, respectively (p < 0.001).

Conclusions: The initial BVAS above 7.5, and baseline FAR above 24.97 are factors associated with renal involvement. The results of this study may provide the basis for identifying individuals at high risk for renal involvement and, consequently, for more rigorous monitoring.

Objectives: High rates of morbidity and mortality are a result of trauma being a significant health burden in Saudi Arabia. We evaluated the current trends of primary healthcare (PHC) physicians in Saudi Arabia toward patients with bleeding and their referral awareness for percutaneous endovascular arterial embolization (EAE).

Methods: We formulated a 13-question survey to assess PHC physicians' knowledge regarding decision-making and appropriate approaches to manage patients with traumatic and non-traumatic abdominopelvic and lower limb bleeding. We conducted in-person surveys with various specialists with varying levels of clinical experience in Saudi Arabia.

Results: Overall, 112 PHC physicians were assessed. Of them, 43.75% had ≥ 5 years of independent practice experience, and 72.3% and 27.7% encountered bleeding patients rarely and routinely, respectively. General practitioners scored lower across all questions than other PHC physicians. Physicians with > 10 years of practice had higher median scores in decision-making questions (p = 0.159). Internists and gynecologists (p = 0.046) and physicians (p = 0.050) in tertiary-care settings had significantly higher median scores on decision-making questions. Pediatricians (p = 0.091) and PHC physicians (p = 0.440) at private institutions had higher median scores on approach appropriateness questions.

Conclusions: PHC physicians in Saudi Arabia require a better understanding of the indications of EAE to avoid referral and triage errors, inefficient use of healthcare resources, and suboptimal patient outcomes.

Objectives: The aim of this study was to systematically assess the quality of different guidelines for the management of patients with hyperthyroidism and to explore and analyze the recommendations and key evidence in different guidelines.

Methods: A systematic search of databases and websites was conducted to identify treatment guidelines for hyperthyroidism. The quality of the included guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. To evaluate the level of agreement among the guidelines, we employed the Measurement Scale of Rate of Agreement (MSRA), extracting and analyzing the evidence supporting these recommendations.

Results: Eleven guidelines for the management of patients with hyperthyroidism were identified. The guidelines from the American Thyroid Association (ATA), the Japanese Thyroid Association (JTA), the European Thyroid Association (ETA, 2022) and the Chinese Medical Association (CMA) had overall quality scores greater than 60% and warranted clinical recommendation. Recommendations vary widely across guidelines, and the main reasons included different emphases on the diagnosis of hyperthyroidism, different target populations, irrational selection of evidence and geographic variation.

Conclusions: The quality of hyperthyroidism treatment guidelines is variable, and treatment recommendations vary greatly from guideline between guidelines. Analyzing and improving the causes of inconsistencies in recommendations for patients with hyperthyroidism could be a reasonable and effective way for developers to improve the quality of guidelines for the management of hyperthyroidism.

Purpose: Our study aimed to discern disparities in metabolic, hormonal profiles, and comorbidities among patients with pituitary Cushing (PC), adrenal Cushing (AC), and Mild autonomous cortisol secretion (MACS).

Methods: We conducted a retrospective analysis involving 76 patients diagnosed with PC (n = 26), AC (n = 21), and MACS (n = 29) at our clinic. We compared the groups' demographic data, clinical characteristics, biochemical profiles, hormonal analyses, and surgical interventions.

Results: No significant differences were noted in age, height, body mass index, or gender distribution among the groups, although a higher proportion of females was observed across all three groups. However, PC patients exhibited markedly elevated 24-hour urinary cortisol levels compared to AC and MACS patients. Furthermore, alanine aminotransferase, triglycerides, very low-density lipoprotein, insulin, and basal cortisol levels were significantly elevated in PC and AC cases compared to MACS cases. Interestingly, no significant differences were observed in terms of comorbidities among the groups.

Conclusion: Our findings suggest that urinary cortisol levels were significantly higher in the PC group than in the AC and MACS groups, potentially indicating that high-amplitude adrenocorticotropic hormone stimulation may lead to increased cortisol secretion in PC patients. The increased utilization of imaging methods has facilitated the earlier detection of adrenal incidentalomas, enabling the diagnosis of adrenal Cushing's cases with milder cortisol elevations. Additionally, the severity of disease symptoms worsens with increasing cortisol levels.Notably, moderate increases in cortisol are associated with heightened comorbidities, underscoring the importance of vigilant management in Cushing's syndrome patients. Despite a lower degree of hypercortisolism in MACS, there were no differences in comorbidities, suggesting that even mild cortisol secretion abnormalities are sufficient to establish the presence of comorbidities. Even moderate increases in cortisol levels can impact bone metabolism.