Postgraduate medicine最新文献

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.

Background: Dysphagia is a common condition in infants and young children, particularly among those with neurodevelopmental disabilities. The management of pediatric dysphagia requires customized approaches based on individual clinical features. This report describes our experience in managing pediatric dysphagia using a locust bean- and xanthan gum-based thickener (ThickenUp® Junior), which offers stable consistency and preserves the original taste of liquids.

Case report: Four cases were discussed to highlight the use of the new thickener. Each case illustrates different aspects of dysphagia management, such as improving swallowing safety, enhancing oral control, and maintaining nutritional intake through tailored thickening strategies. Our experience demonstrates the importance of using specialized thickening agents to prevent aspiration pneumonia and, ultimately, improve the well-being of affected children. We also highlighted the importance of individualized treatment plans, which consider each child's unique needs. A comprehensive evaluation by a multidisciplinary team led to an effective treatment strategy tailored to the child's specific condition and challenges.

Conclusions: The new locust bean- and xanthan gum-based thickener is effective in managing dysphagia and preventing complications in infants and young children. Such agents can improve swallowing safety, enhance oral control, and maintain nutritional intake, ultimately improving the well-being of the affected children.

Purpose: Limited studies have examined the relationship between plasma aldosterone concentration (PAC) and arterial stiffness progression. This study aimed to investigate the longitudinal association between baseline PAC and arterial stiffness progression in hypertensive patients.

Patients and methods: This was a longitudinal study conducted at the Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region between April 2020 and October 2023. The study included 1,138 hypertensive patients who had completed two measurements of brachial-ankle pulse wave velocity (baPWV) over the study period. Arterial stiffness was quantified using baPWV, and progression was assessed by the baPWV change rate, calculated as the absolute difference between baseline and follow-up baPWV divided by the follow-up time in years. The primary outcome was the association between baseline PAC and baPWV change rate.

Results: Multivariate linear regression analyses indicated that a 10-unit increase in baseline PAC was significantly associated with a 19.60 cm/s/year increase in baPWV change rate (95% CI, 9.93 to 29.21). This association remained significant after adjusting for potential confounders, including age, sex, body mass index, smoking status, systolic and diastolic blood pressure, total cholesterol, and the use of antihypertensive medications. Multivariable restricted cubic splines analysis confirmed a significant dose-response relationship between baseline PAC and baPWW change rate (P for overall trend = 0.002).

Conclusion: Higher baseline PAC levels were associated with faster progression of arterial stiffness in hypertensive patients, suggesting a potential role for aldosterone in vascular health. These findings warrant further investigation.

Aim: This study aims to clarify hematological parameters, transfusion requirements, and adverse events of preoperative intravenous (IVIS) versus oral iron supplementation (OIS) in elective surgery patients.

Methods: We conducted a comprehensive literature search across multiple databases up to 10 December 2023. Twelve RCTs involving 930 participants met our eligibility criteria. Our analysis focused on post-treatment hemoglobin levels, changes in hemoglobin from baseline, ferritin levels, hemoglobin attainment rates, transfusion requirements, and adverse events. We employed the random-effects model for data synthesis, calculating pooled standard mean differences (SMD) or mean differences (MD) or risk ratios (RR) with 95% confidence intervals (CI). Methodological quality was assessed using the Cochrane ROB 2 tool. The GRADE approach evaluated the confidence in effect estimates.

Findings: IVIS significantly improved post-treatment hemoglobin levels (MD = 0.77 g/dL, 95% CI [0.30 to 1.23]), hemoglobin increments (MD = 0.69 g/dL, 95% CI [0.01 to 1.37]), and ferritin levels (MD = 260.03 ng/mL, 95% CI [119.65 to 400.42]) compared to OIS. IVIS also led to a higher hemoglobin attainment rate (RR = 1.88, 95% CI [1.24 to 2.86]). No significant differences were noted in transfusion rates or volumes. IVIS was associated with fewer digestive (RR = 0.10, 95% CI [0.05 to 0.22]; I2 = 0%) but more pain-related adverse events (RR = 7.79, 95% CI [1.78 to 34.07]; I2 = 0%). Hospital stay durations and mortality rates were similar between the two groups.

Interpretation: IVIS offers a superior improvement in hematological parameters for elective surgery patients but not reducing transfusion needs compared to OIS. While IVIS has fewer digestive adverse events, it increases pain-related complications. These findings highlight the importance of personalized approaches in selecting iron supplementation methods, carefully balancing time, efficacy, and adverse event profiles.

Registration: PROSPERO CRD42023483284.

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.

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.

Acute kidney injury (AKI) is a well-established and serious complication associated with cardiovascular revascularization procedures, regardless of its severity. According to the 2023 annual report of the National Institute of Diabetes and Digestive and Kidney Diseases - United States Renal Data System, the incidence of cardiovascular disease-related AKI hospitalizations has been steadily increasing over the past decade. Coronary artery bypass grafting (CABG), on the other hand, remains one of the most frequently performed major surgical procedures in the United States, with an estimated 400,000 surgeries conducted annually. However, predicting the true incidence of acute kidney injury due to coronary artery bypass graft surgery (AKI-CABG) is challenging due to various factors. The reported incidence in literature is anywhere between 1% to 50%. Although healthcare teams employ various supportive measures to prevent its occurrence, a single universally effective preventive intervention for AKI-CABG remains elusive. This article focuses on a critical evaluation of the PROTECTION trial, a pioneering study evaluating the hypothesis that intravenous amino acid infusion would reduce the incidence of AKI-CABG using intravenous amino acid therapy (Isopuramin 10%, Baxter) in patients undergoing elective CABG surgery.

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.

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.