Postgraduate medicine最新文献

Background: Periprosthetic joint infection (PJI) is a severe complication of total joint arthroplasty (TJA), with traditional risk factors including diabetes and obesity. Emerging evidence suggests functional gastrointestinal disorders (FGIDs) may influence systemic inflammation and infection susceptibility. This study investigated whether preexisting FGIDs are independent risk factors for PJI.

Methods: A retrospective 1:1 matched case-control study analyzed 896 patients (448 PJI vs. 448 non-PJI) undergoing primary TJA (2013-2023). PJI was diagnosed using modified 2018 Musculoskeletal Infection Society criteria, and FGIDs (irritable bowel syndrome [IBS], functional diarrhea [FD], functional constipation [FC]) were classified per Rome IV criteria. Multivariable logistic regression identified PJI risk factors after adjusting for demographics, comorbidities, and surgical variables.

Results: Univariate analysis revealed significantly higher FC prevalence in PJI cases (14.3% vs. 8.3%, p = 0.0043), while IBS and FD showed no association. Multivariate analysis confirmed FC as an independent PJI risk factor (odds ratio [OR] = 1.844, 95% confidence interval [CI]:1.199-2.872, p = 0.0059), alongside diabetes (OR = 1.714, 95%CI:1.116-2.661, p = 0.0148), and surgery duration >2 hours (OR = 2.220, 95%CI:1.242-4.125, p = 0.0088). Perioperative antibiotic usage reduced PJI risk (OR = 0.405, 95%CI:0.232-0.686, p = 0.0010).

Conclusion: Functional constipation was identified as a novel independent risk factor for PJI, alongside established metabolic comorbidities and prolonged surgery. These findings underscore the gut-joint axis in PJI pathogenesis and advocate integrating FGID screening into preoperative risk stratification. Antibiotic prophylaxis remains critical for minimizing infection risk in TJA patients.

Background: Microvascular dysfunction (MD) is advocated as one of the main pathogenic mechanisms of Takotsubo syndrome (TTS). Several studies investigated MD in TTS using different techniques; however, no systematic review of these data is currently available.

Methods: We searched the main scientific database (Embase, Medline, Scopus, PubMed) for articles written in English language using the following keywords: ('takotsubo' OR 'broken heart' OR 'apical ballooning' OR 'stress cardiomyopathy') AND ('microvascular'). Case reports: studies not performed in human subjects or investigating microvascular function in organs other than the heart were excluded.

Results: 35 studies matched the inclusion criteria. Microvascular function was assessed by standard coronary angiography-derived indexes (n = 17), invasive measurement (n = 10, index of microcirculatory resistance (IMR) in n = 7), echocardiography (n = 5), nuclear medicine (n = 3), and cardiac magnetic resonance imaging (CMR) in n = 2, with some studies applying more than 1 technique. When established cutoff values were used, MD prevalence largely varied (35% to 100%). Although comprehensive clinical correlates were scarcely reported, MD was consistently associated with higher systolic impairment. Blood-based inflammatory biomarkers analysis was performed in one study only, providing inconclusive results. Clinical outcomes associated with MD were reported in four studies including higher rates of major cardiovascular events and long-term mortality.

Conclusions: MD in TTS has a variable prevalence. It is absent in a relevant proportion of the cases, making it questionable as it should be considered a pre-requisite for disease onset. The presence and extent of MD in TTS is a promising prognostic marker; no data in humans currently confirm its role as a therapeutic target.

Objectives: Heart failure (HF) with reduced (HFrEF) or mildly reduced ejection fraction (HFmrEF) frequently coexists with atrial fibrillation (AF), leading to worse prognosis and greater therapeutic complexity. Although beta-blockers (BBs) are a cornerstone of HF treatment, their benefit in patients with AF remains unclear.

Methods: We analyzed 1088 patients with stable chronic HF and left ventricular ejection fraction < 50% enrolled in the multicentre FAR NHL registry. Patients were stratified by the presence of AF and achieved BB dose: low ( < 25%), medium (25-49%), or high (≥50% of target). The primary endpoint was a composite of all-cause mortality, hospitalization for acute HF, left ventricular assist device (LVAD) implantation, or heart transplantation.

Results: AF was present in 379 patients (34.5%). BBs were prescribed to 94% of patients, but only 17% achieved high-dose therapy. The event rate was higher in AF patients (28.0%) than in those without AF (20.5%, p = 0.005). High BB dose was independently associated with a lower risk of the primary endpoint (HR 0.62, 95% CI 0.48-0.80; p < 0.001), consistently across both rhythm group.

Conclusion: Higher BB doses were associated with improved outcomes in patients with chronic HF, regardless of AF status. These real-world data support up-titration of BBs as a key component in optimized guideline-directed therapy, even in patients with coexisting AF.

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.

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.

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.

Objectives: Recent studies have suggested that serum 25-hydroxyvitamin D₃ (s25-OHD₃) may modulate immune responses in allergic diseases. However, the relationship between s25-OHD₃ levels, allergic rhinitis (AR) severity, and allergen sensitization remains unclear. This study aimed to investigate the association between s25-OHD₃ levels and AR severity, including the potential role of allergen sensitization.

Methods: This retrospective study, conducted at Ankara Bilkent City Hospital between 2019 and 2024, included 343 children with AR aged 2 to 18 years. Patients were evaluated for s25-OHD₃ levels, allergen sensitization (via skin prick test and/or serum-specific IgE), and clinical characteristics. AR severity was classified according to Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines, and clinical response to vitamin D supplementation was reassessed after 12 weeks. Risk factors for increased AR severity were identified by regression analysis.

Results: The median s25-OHD₃ level was 16.0 ng/mL (IQR: 10.8-22.0). An inverse correlation was observed between age and s25-OHD₃ levels (r_s = -0.202, p < 0.001). Lower s25-OHD₃ levels were significantly associated with greater AR severity (p < 0.001). Additionally, patients with concomitant allergic diseases - particularly those with allergic conjunctivitis, asthma, and atopic dermatitis - had significantly lower s25-OHD₃ levels (p = 0.004, p = 0.032, and p = 0.042, respectively). Notably, sensitization to cat dander was also associated with reduced s25-OHD₃ levels (p = 0.043). Multivariable regression analysis identified lower s25-OHD₃ levels, coexisting allergic conjunctivitis, pollen sensitization, and polysensitization as independent risk factors associated with increased AR severity. Furthermore, a significant reduction in AR severity was observed following vitamin D supplementation (p < 0.001).

Conclusion: This study underscores the impact of s25-OHD₃ deficiency on the severity of AR and highlights the importance of evaluating s25-OHD₃ levels in the management of pediatric AR to support the development of targeted therapeutic approaches.

Chronic kidney disease (CKD) is a global health concern strongly associated with cardiovascular disease (CVD) and high mortality rates. Glomerular filtration rate (GFR) abnormalities, such as glomerular hyperfiltration (GHF) and selective glomerular hypofiltration syndrome (SHS), although not traditionally included in the CKD framework, share chronic inflammation as a pivotal mechanism driving systemic complications and CVD progression. In recent decades, GHF has gained substantial importance due to the high cardiovascular (CV) risk and mortality observed in populations within the highest tertiles of GFR, as determined by both estimation formulas (estimated GFR (eGFR)) and clearance (Cl) of exogenous substances. It is frequently observed in conditions such as obesity, diabetes, and metabolic syndrome. This hyperfiltration state is linked to endothelial dysfunction and CKD progression, often presenting with albuminuria, an independent marker of oxidative stress and CVD. SHS, on the other hand, involves the selective hypofiltration of medium-sized molecules (e.g. cystatin C) (Cys C), leading to proteomic alterations and the retention of pro-inflammatory molecules. This dysregulation intensifies systemic inflammation, atherosclerosis, and endothelial dysfunction, emphasizing SHS's role in CVD pathogenesis. The accuracy of CKD diagnosis is challenged by variability in eGFR methods, with formulas based on Cys C and creatinine (Cr) providing superior predictive value as biomarkers of risk in CKD and for detecting GFR abnormalities like GHF and SHS. Early identification and targeted management of these classical and non-classical GFR alterations may reduce the CVD burden and improve outcomes, underscoring the need for consensus definitions and multidisciplinary approaches to expand the CKD paradigm.