Postgraduate medicine最新文献

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.

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.

Objectives: To investigate the association of four liver fibrosis scores - Fibrosis-4 (FIB-4), AST/ALT ratio, AST-to-platelet ratio index (APRI) and Gamma-glutamyl transferase-to-platelet ratio index (GPRI) - and clinical outcomes in ambulatory patients with heart failure (HF).

Methods: We conducted a retrospective study involving 2379 patients with HF referred to a specialized clinic from January 2010 to June 2022. We used multivariable Cox´s regression models to study the association between liver fibrosis scores and long-term clinical outcomes (all-cause death and the combined endpoints all-cause death or HF hospitalization and cardiovascular death or heart transplantation). Areas under receiver-operator curves were used to evaluate the discriminative capacity of each score for predicting 1-year clinical outcomes, as well as to analyze their incremental predictive value in addition to the broadly validated MAGGIC risk score.

Results: Median follow up was 1568 days. GPRI was identified as an independent predictor of all-cause death or HF hospitalization (HR 1.12, 95% CI 1.07-1.18), all-cause death (HR 1.14, 95% CI 1.08-1.20) and cardiovascular death or heart transplantation (HR 1.10, 95% CI 1.03-1.17). FIB-4 and AST/ALT ratios were also independently associated with all-cause mortality. According to receiver-operator curve analyses, GPRI showed the best discriminative capacity among the four liver fibrosis scores evaluated in the study to predict 1-year clinical outcomes. The predictive value of GPRI was incremental to the one of the MAGGIC risk score.

Conclusions: Liver fibrosis scores are associated with long-term clinical outcomes in ambulatory patients with HF. In our study, the predictive capacity of GPRI outperformed the one of FIB-4, APRI and AST/ALT and was incremental to the one of the MAGGIC risk score.

The following systematic review aimed to gather information on the effectiveness of Respiratory Muscle Training (RMT) with Multiple Sclerosis (MS) patients. The method followed the ENTREQ and PRISMA protocol. MEDLINE, Cochrane, and Science Direct databases were used to source relevant literature. Articles included participants diagnosed with MS in randomized, controlled trial studies with objectively measured outcomes, and RMT methods were standardized. Eleven students were included in the results (n = 396, 50.5 ± 9.8 years, 68% F 31% M) and show that RMT (minimum 8 weeks of training) is effective in improving respiratory muscle strength (MIP in 7 out of 9 studies, MEP in 6 out of 11 studies and FVC in 6 out of 7 studies) and health-related outcomes, including mobility. Although muscle strength increased, increases in FVC had moderate effects on functional ability, which were negligible, and patient-reported fatigue. Findings suggest that muscle strength increases were predominantly in inspiratory muscles, and expiratory results were combined. However, the review shows a lack of research concerning the use of RMT and its prescription for MS patients.

Objective: This study aimed to translate and validate the Adherence to Refills and Medications Scale into Traditional Chinese (ChARMS-T) and to investigate common barriers to medication adherence among patients with type 2 diabetes (T2D) in Taiwan.

Methods: The ChARMS-T was developed through translation and application phases. During the translation phase, the scale underwent forward translation, backward translation, and cognitive debriefing. In the application phase, the finalized ChARMS-T was administered to patients with T2D at five Taiwan community pharmacies over eleven months starting in June 2023. Psychometric properties were assessed using criterion validity, construct validity through confirmatory factor analysis, and reliability through McDonald's omega.

Results: A total of 343 participants completed surveys. Factor analysis of the 12-item ChARMS-T revealed two dimensions: medication-taking (8 items) and medication refill (4 items). The instrument demonstrated acceptable internal consistency, with McDonald's omega scores of 0.841 for medication-taking and 0.647 for medication refill. The medication refill subscale showed strong agreement with the objective refill measure, proportion of days covered, with a coefficient of 0.84, suggesting that these measures evaluate similar constructs. Evidence of known-groups validity was demonstrated by a significant difference between ChARMS-T scores and glycemic control (p = 0.047). Patients with good glycemic control had a significantly higher adherence rate to both refills and medication-taking compared to those with poor glycemic control. The most frequently reported barriers to medication-taking were carelessness (55.7%), forgetfulness (54.8%), and frequent dosing intervals (43.1%). For medication refills, 9.6% of the participants identified a lack of planning as the main reason for not refilling their diabetes medications on time, followed by forgetfulness (7.6%).

Conclusions: The ChARMS-T identified a broader range of non-adherence reasons and demonstrated good psychometric properties. It can be integrated into practice settings for screening and follow-up to enhance medication adherence through effective communication between healthcare professionals and patients, ultimately improving long-term patient health outcomes.

Background: It has been reported that phenylalanine (Phe)-restricted diets may have negative effects on bone health in patients with classical phenylketonuria (cPKU). We aimed to evaluate bone mineral density (BMD) in adults with cPKU and determine the risk factors associated with low BMD.

Methods: Eighty adult patients with cPKU were examined, including 41 women and 39 men. The age range was 18.3-39.4 years (median 22.8). The femoral and lumbar BMD were measured by dual energy X-ray absorptiometry. The patients were evaluated in two groups with low (Z-score ≤-2) and normal BMD (Z-score > -2).

Results: Low BMD was detected in 20 patients (25%). The low BMD group had significantly more males (75% vs 40%, p < 0.01) and lower mean body mass index (BMI, 22.4 vs 24.5 kg/m², p = 0.02). Paradoxically, mean blood calcium and 25-hydroxy vitamin D levels were higher in the low BMD group, but only marginally (10.0 vs 9.8 mg/dl and 25.1 vs 21.0 µg/L respectively, p < 0.05). The groups did not differ significantly with regards to age, mean Phe levels at diagnosis, median Phe levels above the age of 12 years, other nutritional parameters or vitamin-mineral supplementation. There was no history of clinical fractures.

Discussion: Although osteopenia, osteoporosis and low BMD have been reported in PKU, conflicting data also exist. Our study of a large adult cPKU cohort strongly supports previously published limited data that suggest male sex and low BMI confer a higher risk for low BMD in cPKU; and age, Phe levels and dietary adherence do not. In our study, although the patients were young, low BMD was quite common (25%). Bone health should be evaluated even in young adults with cPKU, especially in males and those with low BMI, regardless of treatment compliance and vitamin-mineral status. Prospective studies reporting on clinical outcomes such as bone pain or fractures will be valuable in the coming years.

Objective: To compare the demographic and clinical characteristics of familial Mediterranean fever (FMF) patients according to age at disease onset and evaluate the dose effect of the number of pathogenic or likely pathogenic exon 10 mutations of the MEFV gene on disease severity.

Methods: This medical record review study was performed on 485 pediatric FMF patients with uni- or biallelic exon 10 mutations of the MEFV gene (M694V, M694I, M680I, V726A, R761H, T267I). Patients were grouped according to age at disease onset (Group 1:<6 years; Group 2:6-11 years; and Group 3:>11 years). Disease severity was assessed by the international severity scoring system for FMF (ISSF).

Results: Of the patients, 294 (60.6%) were classified in Group 1, 152 (31.4%) in Group 2 and 39 (8%) in Group 3. The mean elapsed time to diagnosis was 26.7 ± 27.4 months in Group 1 and was higher than the other groups (p < 0.001). During the attack, fever was higher in Group 1, arthritis in Group 2, and chest pain in Group 3 (p < 0.001). The median ISSF score was similar in patients with uni- or biallelic mutations in Group 1 and 3 (p = 0.086, p = 0.35, respectively) but lower in heterozygous patients in Group 2 (p < 0.001). In Groups 1 and 2, mild disease severity was higher in heterozygotes, while moderate disease severity was higher in homozygotes (p = 0.034, p = 0.001, respectively).

Conclusion: The presence of pathogenic or likely pathogenic homozygous or compound heterozygous mutations in exon 10 of the MEFV gene in patients with early-onset disease is associated with a more severe disease course compared to patients with heterozygous mutations. The gene dose effect of the number of mutations on disease severity is more common in children aged 6-11 years.