Postgraduate medicine最新文献

Background: Chemotherapy-induced myocarditis (CIM) is a rare but life-threatening complication with limited guidelines regarding venoarterial extracorporeal membrane oxygenation (VA-ECMO) as salvage therapy.

Case report: We present the case of a 32-year-old female with metastatic thymoma who developed fulminant CIM following paclitaxel-based chemotherapy. Despite aggressive multimodal immunosuppressive therapy, she progressed to refractory cardiogenic shock and pulseless ventricular tachycardia, necessitating emergent VA-ECMO. Hemodynamic stability was achieved, and she was successfully decannulated after a period of support with signs of improving cardiac function. However, she suffered a sudden cardiac arrest due to ventricular fibrillation shortly after decannulation. Although return of spontaneous circulation (ROSC) was achieved, life-sustaining therapies were subsequently withdrawn per family's decision in light of the grave prognosis.

Conclusions: This case demonstrates that VA-ECMO can serve as a crucial salvage bridge in fulminant CIM. However, it starkly highlights the precarious nature of recovery. The fatal arrhythmia post-decannulation underscores that the resolution of life-threatening electrical instability may lag significantly behind the recovery of systolic function, a critical learning point for managing such cases. This dissociation, combined with the unique challenges in immunocompromised oncology patients, demands meticulous patient selection, prolonged post-weaning monitoring, and proactive multidisciplinary decision-making.

Objective: This study aimed to evaluate the progression rate of undifferentiated connective tissue disease (UCTD) to defined CTDs by applying two sets of UCTD criteria alongside the most recent CTD classification criteria.

Methods: A retrospective review was conducted on 1342 patients who underwent antinuclear antibody (ANA) testing at a rheumatology outpatient clinic between February 2021 and February 2023. UCTD was defined in patients exhibiting autoimmune features without meeting criteria for a specific CTD. Patients were categorized into two groups: (1) ANA-positive with disease duration ≥3 years (Mosca) and (2) positive finding for at least one of the following serological markers (ANA, rheumatoid factor, anti-scl 70, SS-A or SS-B, Jo-1 antibody, sedimentation rate (two times normal), C-reactive protein) in the absence of infection, regardless of disease duration (Kinder).

Results: A total of 119 patients with UCTD (95% women) were evaluated, with a median follow-up time of 34.1 (IQR: 21.4-52.7) months. Sixteen patients (13%) progressed to defined CTDs or rheumatoid arthritis (RA): primary Sjögren's syndrome (n = 7), RA (n = 5), systemic sclerosis (n = 3), and systemic lupus erythematosus (n = 1). The median time for evolution was 34.8 (IQR: 17.9-54.8) months. Approximately half of the patients met either set of UCTD criteria. There was no difference in either the progression rate (12.1% vs. 14.8%, p = 0.81) or the time to classification as CTD or RA [28.2 (11.7-39.9) vs. 39.2 (24.6-67.4) months, p = 0.14] when using the Kinder or Mosca criteria.

Conclusion: Application of the most recent CTD classification criteria revealed a 13% progression rate from UCTD to defined CTDs or RA during a three-year median follow-up. In patients with suspected CTD, evaluation of serological markers beyond ANA may contribute to the diagnosis of UCTD. The establishment of standardized definitions for UCTD is essential to improve the methodological consistency of future studies and to facilitate more accurate prognostic assessments.

Introduction: Hyperkalemia is a critical electrolyte imbalance in neonatal intensive care unit (NICU), linked to increased mortality. This study aimed to determine the prevalence, etiological factors, and clinical outcomes of hyperkalemia in neonates admitted to the NICU over a 10-year period, with a specific focus on differentiating actual hyperkalemia from pseudohyperkalemia according to gestational age - based thresholds.

Materials and methods: Data from NICU admissions over 10 years were analyzed. Hyperkalemia was defined as potassium levels ≥6 mmol/L in term neonates and >6.5 mmol/L in preterm. Cases of pseudohyperkalemia, primary etiology, and mortality were assessed.

Results: Among 5997 admissions, hyperkalemia was observed in 4.9% of cases, while true hyperkalemia was confirmed in 1.6%. Pseudohyperkalemia was the most common type. Actual hyperkalemia was more frequent in term neonates (p = 0.016). Acute kidney injury (AKI) was identified in 43.6% of cases. In term neonates, the most common causes were asphyxia, AKI, and congenital adrenal hyperplasia, whereas in preterms, they were AKI, hypoxia, and hemorrhage. A negative correlation was found between Apgar scores and potassium levels (p < 0.001). Mortality rates were 7.2% in neonates without actual hyperkalemia and 37.2% in those with it.

Conclusion: Hyperkalemia is a common and serious condition in NICUs, requiring prompt differentiation of pseudohyperkalemia from actual hyperkalemia. Given its high mortality risk, rapid etiology-specific treatment and potassium-lowering therapies are essential for managing actual hyperkalemia.

Background: Post-operative care of head and neck cancer (HNC) patients is complex, posing significant learning demands on junior trainees. Mnemonics are widely used as learning aids in medical education. We hypothesized that a specialized mnemonic would be beneficial for HNC ward round (WR) education.

Methods: The 'STRIDOR' mnemonic was developed after a literature review and a Delphi process with an expert panel of HNC surgeons. A pilot randomized educational intervention blinded trial was conducted. Recruited medical students were randomized into two groups: Group 1 (n = 10) received an educational intervention (lecture on conducting a HNC-WR); Group 2 'mnemonic' (n = 10) received the same intervention with explicit teaching on the STRIDOR mnemonic. Both groups then participated in a simulated scenario with a simulated post-operative HNC patient. Subjective (Visual Analogue Scale 'VAS') and objective scores were compared between both groups.

Results: The simulation scenario lasted an average of ≈13 minutes. Both groups scored very low on subjective confidence in conducting a HNC WR (1.93/10 VAS) before intervention but showed significant improvement (5.9/10 VAS) after the intervention (p < 0.001). No statistically significant improvements in either subjective or objective (technical and non-technical) scores, or in scenario timings, were demonstrated in Group 2 'mnemonic' compared to Group 1.

Conclusion: Educational interventions targeted toward a systematic approach to conducting a WR are valuable and should be considered for curriculum inclusion. Although we could not demonstrate statistical significance, the STRIDOR mnemonic should be investigated as a learning aid in future larger studies.

Objectives: Serotonin syndrome (SS) is a life-threatening emergency that develops as a result of increased serotonin amount or activity in the synaptic cleft. The present study aimed to determine the clinical findings in serotonergic drug intoxications in children that may alert clinicians about the development of SS.

Methods: The patients aged between 1 to 18 years, who were admitted to the pediatric emergency department (PED) because of drug intoxications between September 2022 and August 2024, were analyzed retrospectively. Patients with a history of taking one or more serotonergic drugs were included in the study. Patients were divided into two groups: SS and without SS. The sensitivity, specificity, negative and positive predictive value (PPV) of the Hunter's criteria and SS-related symptoms were evaluated.

Results: A total of 162 patients were included in the study. SS developed in 25 (15.4%) of the patients. SS developed in 23 (21.1%) of 109 patients receiving SSRI group drugs, while SS developed in two (4.8%) of 42 patients receiving non-SSRI group drugs (p = 0.015). Nineteen (76%) of the patients diagnosed with serotonin syndrome were also diagnosed with SS according to Hunter's criteria, and the sensitivity and specificity of Hunter's criteria in the diagnosis of SS in pediatric patients were 76% and 100%, respectively. The specificity and PPV were 100% for spontaneous clonus, inducible clonus, ocular clonus, hyperreflexia, and hyperthermia in the diagnosis of serotonin syndrome. The symptoms with the highest sensitivity were mydriasis (76%) and tremor (64%). All patients with serotonin syndrome were treated with cyproheptadine, and clinical findings improved.

Conclusion: SS developed in 15.4% of patients with serotonergic drug intoxication, and the sensitivity of Hunter's criteria for the diagnosis of SS was 76%. The combined use of Hunter's criteria and clinician decision in the diagnosis of childhood SS may be more useful.

Objective: Severe pneumonia is typically characterized by severe pulmonary inflammatory responses. This study evaluated the predictive value of D-dimer (DD) and neutrophil-to-lymphocyte ratio (NLR) for disease severity in children with severe pneumonia.

Methods: Children with severe pneumonia (280 cases) were enrolled and divided into the critical and non-critical groups based on the pediatric critical illness score (PCIS). Clinical data were collected at patients' initial admission. Correlations of DD and NLR with the PCIS, their predictive value and the independent predictors for disease severity in children with severe pneumonia were assessed by Spearman test, receiver operating characteristic curve and multivariate logistic regression. Outcomes were determined as per the 28-day disease progression.

Results: The critical group showed higher DD and NLR than the non-critical group. DD and NLR negatively correlated with the PCIS. Children in the higher DD quartile group showed higher systolic blood pressure (SBP), NLR and procalcitonin, and lower platelet and PCIS. Children in the higher NLR quartile group had higher SBP, DD and procalcitonin, and platelet and lower PCIS. Areas under the curve to predict severe pneumonia severity were 0.805, 0.883 and 0.918 for DD, NLR and their combination, suggesting superior diagnostic value of their combination for disease severity. The critical group (59.05%) had higher 28-day poor outcomes of pneumonia than the non-critical group (18.29%). DD and NLR were independent risk factors for the disease severity in severe pneumonia children.

Conclusion: Elevated DD and NLR have certain predictive value for disease severity and poor prognosis in severe pneumonia children.

Objective: To evaluate the predictive value of the platelet-albumin-bilirubin (PALBI) score for hepatic failure after transarterial chemoembolization (TACE) in patients with non-small hepatocellular carcinoma (HCC) (tumor diameter > 5 cm).

Methods: A retrospective study included 577 non-small HCC patients who underwent TACE between January 2018 and December 2024. Patients were stratified by PALBI grade (Grade 1: ≤-2.53; Grade 2: > -2.53 to ≤-2.09; Grade 3: > -2.09). Hepatic failure was defined and graded (A-C) according to ISGLS criteria. The predictive efficacy of PALBI, ALBI, and Child-Pugh scores was compared using ROC curves.

Results: Hepatic failure occurred in 28.2% (163/577) of patients (Grade A: 22.0%; B: 4.6%; C: 1.5%). Hepatic failure incidence significantly increased with PALBI grade: 10.31% (Grade 1), 27.83% (Grade 2), and 78.95% (Grade 3) (p < 0.001). PALBI demonstrated superior predictive efficacy (AUC = 0.746) compared to ALBI (AUC = 0.702, p = 0.004) and Child-Pugh (AUC = 0.706, p = 0.075). Multivariate analysis identified ascites, AST, and total bilirubin as independent risk factors for hepatic failure (p < 0.05).

Conclusion: The PALBI score is an effective tool for predicting hepatic failure after TACE in non-small HCC patients. PALBI Grade 3 indicates high risk (78.95%), suggesting preoperative liver protection therapy before TACE. PALBI outperforms ALBI and Child-Pugh scores in risk stratification.

Background: Sepsis is a major health concern with high mortality, which is associated with immunosuppression. CD28, a co-stimulatory molecule on T lymphocytes, promotes T cell proliferation, survival, and cytokine production. CD4⁺CD28⁺ T cells play an important role in immune activation and regulation. This study aimed to determine whether CD4⁺CD28⁺ T lymphocytes were associated with 28-day mortality in patients with sepsis.

Methods: A retrospective analysis was performed in 80 adult patients with sepsis admitted to the department of intensive care unit. Peripheral blood CD4⁺CD28⁺ T cells were measured within 24 h of admission using flow cytometry. Independent predictors of 28-day mortality were identified using univariate and multivariate Cox regression analyses.

Results: In total, 80 patients with sepsis were included, of whom 15 (18.8%) died within 28 days. Most patients were older than 60 years (56/80, 70.0%) and male (52/80, 65.0%). The predominant sources of infection were the lung (47/80, 58.8%) and abdomen (28/80, 35.0%), with bacteria being the most common pathogens (68/80, 85.0%). Compared to non-survivors, survivors had lower Sequential Organ Failure Assessment (SOFA) scores, lower rates of septic shock and acute kidney injury (AKI), a higher proportion of CD4⁺CD28⁺ T cells > 75.9%, and a lower proportion of CD8⁺ CD28⁺ T cells ≤39.9%. Receiver operating characteristic analysis depicted that CD4⁺CD28⁺ T cells (cutoff value was 75.9%) showed an area under the curve of 0.732, a sensitivity of 66.67%, and a specificity of 80.00%. The Kaplan-Meier analysis demonstrated significantly better survival in patients with CD4⁺CD28⁺ T cells > 75.9% than in those with ≤75.9%. In univariate Cox regression analysis, SOFA score ≥6, septic shock, AKI, CD8⁺CD28⁺ T cells ≤39.9%, and CD4⁺CD28⁺ T cells ≤75.9% were associated with 28-day morality in patients with sepsis. Multivariate Cox analysis indicated that SOFA score ≥6, AKI, and CD4⁺CD28⁺ T cell ≤75.9% were independent risk factors for 28-day morality of sepsis patients.

Conclusion: A low percentage of CD4⁺CD28⁺ T lymphocytes (≤75.9%) is an independent risk factor for 28-day mortality in patients with sepsis.

Background: Although oxidative stress has been implicated in PE, findings on antioxidant and oxidative DNA damage markers remain inconsistent. This study aimed to assess the plasma levels of the antioxidant biomarkers sirtuin 1 (SIRT1) and superoxide dismutase 2 (SOD2), as well as the oxidative DNA damage marker 8-hydroxy-2'-deoxyguanosine (8-OHdG), and to evaluate their correlation with clinical parameters in cases of PE.

Methods: This case-control study included 25 women aged 20-45 years, divided into two groups: the PE group (n = 14) and the control group (n = 11). Plasma SIRT1, SOD2, and 8-OHdG concentrations were measured by enzyme-linked immunosorbent assay (ELISA). Pearson correlation coefficients were calculated to determine the relationships between plasma concentrations of these markers and specific clinical parameters in the PE group.

Results: Plasma levels of SIRT1 and SOD2 were significantly higher in the PE group compared to that in the control group, while no significant difference was observed in 8-OHdG. A significant positive correlation was observed between SIRT1 and both systolic and diastolic blood pressures in the PE group compared to that in the control group. In addition, a borderline significant positive association was observed between SOD2 and diastolic blood pressure in the PE group compared to that in the control group.

Conclusion: Increased levels of both plasma SIRT1 and SOD2, along with their positive correlation with blood pressure, suggest a potential role for oxidative stress and antioxidant response in the pathogenesis of PE.