Postgraduate medicine最新文献

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.

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.

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.

Objectives: For many decades, guaifenesin and dextromethorphan have been two of the most well-established and commonly used nonprescription medications to manage cough and cold symptoms. A single source that summarizes the clinical data supporting the use of guaifenesin and dextromethorphan as self-care treatment options in cough and cold could assist healthcare professionals (HCPs) in making informed recommendations to patients. The objective of this narrative review is to discuss the benefits of guaifenesin and dextromethorphan for the management of cough and mucus-related cold symptoms in adults by examining published data on the effectiveness and safety of the products containing these ingredients.

Methods: Literature searches were performed on PubMed, Embase, and MEDLINE to identify randomized, controlled studies comparing guaifenesin or dextromethorphan treatment with placebo control in adults with cough and cold (mucus) symptoms. Of 36 guaifenesin and 53 dextromethorphan clinical studies initially identified by the literature search, 13 guaifenesin and 19 dextromethorphan publications met the predefined inclusion criteria. Additional studies were identified during manuscript development by reviewing the citations of included articles, for a total of 17 guaifenesin and 21 dextromethorphan publications.

Results: Data from studies of guaifenesin and dextromethorphan either used alone or combined with other active ingredients showed statistically significant improvements compared with placebo control in sputum looseness/adhesiveness and reductions in cough frequency/severity, respectively. A small number of studies did not show significant improvements with study drug compared with placebo control. Conflicting data may originate from differences in study design, patient enrollment, and a relatively high placebo control effect across studies.

Conclusion: The data reviewed in this article support the importance of guaifenesin and dextromethorphan in the armamentarium of effective nonprescription treatment options for cough and mucus-related cold symptoms.

Objectives: To review the efficacy of lemborexant (LEM), a dual orexin-receptor antagonist approved in multiple countries for treatment of insomnia in adults, by assessing the consistency of the available LEM objective and subjective evidence.

Methods: Data from 2 pivotal phase 3, randomized, double-blind, parallel-group, placebo (PBO)-controlled studies are reviewed. Study 304 (1-month) and Study 303 (12-months; only first 6 months included here) evaluated the efficacy/safety of LEM 5 mg (LEM5) and LEM 10 mg (LEM10) in adults with insomnia disorder. Objective sleep onset (latency to persistent sleep [LPS]) and sleep maintenance (wake after sleep onset [WASO] and total sleep time [TST]) were assessed with polysomnography in Study 304. Subjective sleep onset latency (sSOL) and sleep maintenance (sWASO and sTST) were assessed with sleep diaries in both studies. Other patient-reported efficacy measures included Insomnia Severity Index-total score (ISI-TS), ISI-daytime functioning (ISI-DF), Fatigue Severity Scale (FSS), and Patient Global Impression-Insomnia (PGI-I).

Results: Compared with PBO, significantly larger decreases (improvements) from baseline in LPS, sSOL, WASO, and sWASO and significantly larger increases (improvements) from baseline in TST and sTST were observed within the first week of LEM treatment (as early as within the first 1-2 nights) and were sustained throughout the treatment period (1-6 months) (all p < 0.05, except for sWASO at Month 1). These improvements aligned with significantly larger decreases (improvements) from baseline in ISI-TS, ISI-DF, and PGI-I (all p < 0.05). Significantly larger decreases (improvement) from baseline in FSS scores were observed at 3 and 6 months (both p < 0.05).

Conclusion: LEM showed concordance in its ability to improve objective and subjective measures of nighttime sleep, as well as daytime functioning and patient perception of nighttime sleep. These findings demonstrate that LEM is effective both objectively and from the patient's perspective, supporting LEM as a valuable treatment option for adults with insomnia.

Objectives: Tinea capitis is one of the most common fungal infections in children around the world. However, the relationship between nutrition and the risk of infection, as well as treatment outcomes, has not been thoroughly studied. This study aimed to explore the relationship between certain micronutrient deficiencies and the occurrence, severity, and treatment response of tinea capitis in children.

Methods: This prospective cohort study included 280 children aged 2-12 years, with 140 confirmed cases of tinea capitis and 140 matched controls from three clinical locations. Detailed nutritional assessments included growth measurements and lab tests for zinc, iron, vitamin D, and protein-energy levels. The cases received standard antifungal treatment and were monitored for 6 months to evaluate treatment results. We employed multivariate analyses to identify relationships between nutritional factors and the occurrence, severity, and treatment outcomes of the disease.

Results: Even after controlling for other variables, zinc deficiency (OR = 2.87, 95% CI [1.71, 4.84], p < 0.001) and vitamin D deficiency (OR = 2.11, 95% CI [1.25, 3.58], p = 0.005) were found to increase the risk of tinea capitis independently. The symptoms and outcomes of treatment were worse in children with multiple nutritional deficiencies. At 8 weeks, children with nutritional deficiencies had a significantly lower rate of clinical cure (44.2%) than those without (71.4%, p < 0.001). The relationship between treatment response and socioeconomic status was significantly influenced by nutritional status.

Conclusions: Low levels of certain micronutrients, especially zinc and vitamin D, are key risk factors for children developing tinea capitis and not responding well to treatment. These findings suggest the potential benefits of integrated nutritional assessment and focused supplementation strategies, which should be evaluated in future interventional trials for pediatric tinea capitis, especially in resource-limited settings.

Introduction: The effects of estrogen on arrhythmias are controversial. While animal studies suggest complex effects, the hypothesis that higher estrogen levels increase women's arrhythmia susceptibility has not yet been fully validated in human studies.

Case report: This case report describes a 30-year-old female patient who frequently experienced palpitations and was initially diagnosed with idiopathic ventricular arrhythmia. However, her symptoms were strongly correlated with her menstrual cycle. She experienced premature ventricular contractions (PVCs) 6 days before menstruation and 5 days before ovulation, which coincided with elevated estrogen levels. After other potential causes were ruled out, a diagnosis of hormone-induced PVCs was established. The patient was treated with a combination of estrogen and progestogen that not only alleviated her palpitations but also relieved her dysmenorrhea and menstrual irregularities. During a 5-month follow-up period, the patient reported no further palpitations.

Conclusion: This case provides clinical support of the hypothesis that elevated estrogen levels can increase vulnerability to ventricular arrhythmias in women. The influence of estrogen on arrhythmias may occur via a biphasic effect that potentially provides antiarrhythmic benefits during phases of low estrogen and increases the risk of arrhythmia during peak estrogen phases. Clinicians should consider hormone-related arrhythmias when young female patients present with palpitations that follow a cyclical pattern that is clearly linked to the menstrual cycle. Such cases warrant thorough history-taking and assessments of sex hormone levels. Hormonal regulation therapy could be an effective treatment strategy; however, its effectiveness and safety require careful evaluation.

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: Life's Crucial 9 (LC9) was recently proposed by adding depression to Life's Essential 8 (LE8) to better predict future health risks. However, its superiority over LE8 in predicting outcomes in individuals with prediabetes or diabetes remains unclear.

Methods: We analyzed data from 7044 individuals with diabetes or prediabetes from the National Health and Nutrition Examination Survey (NHANES). LC9 was calculated as the mean of the LE8 score and a depression score, representing psychological health. We used Cox regression to assess the association of these scores with all-cause and cardiovascular mortality. Receiver operating characteristic curves and reclassification analyses were employed to compare predictive performance.

Results: During a median follow-up of 6.58 years (IQR: 4.67-8.75), 782 participants (11.10%) died, with 243 (3.45%) from cardiovascular causes. Each 10-point increase in LE8 score was associated with a hazard ratio (HR) of 0.807 (95% CI: 0.733-0.888) for all-cause mortality, while LC9 showed a stronger association with HR 0.750 (95% CI: 0.673-0.835). LC9 significantly improved the prediction of all-cause mortality (AUC 0.574 vs. 0.589, p = 0.021), supported by reclassification indices (p < 0.001). However, for cardiovascular mortality, both scores showed similar HRs, and no improvement was observed with LC9.

Conclusions: Incorporating depression into LE8 could improve the prediction of all-cause mortality in diabetic and prediabetic populations. Given its practicality and low cost, routine depression screening may offer a feasible strategy to enhance risk stratification in primary care settings.

Objective: To identify key risk factors associated with mortality in necrotizing fasciitis (NF) and provide clinicians with evidence-based guidance for risk stratification and management.

Methods: A systematic review and meta-analysis was conducted. PubMed, Embase, Web of Science, Cochrane Library, and ProQuest were searched from inception to 19 May 2023, with an update on 31 May 2025. Cohort studies reporting adjusted risk estimates for NF-related mortality were included. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

Results: Of 30,563 identified articles, 14 studies involving 26,242 patients were included. The strongest predictors of NF mortality were advanced age (odds ratio [OR] 1.160, 95% CI 1.100-1.223), cardiopathy (OR 2.210, 95% CI 1.274-3.833), elevated creatinine (OR 2.200, 95% CI 1.127-4.294), and Clostridium infection (OR 6.422, 95% CI 2.171-19.003). Race appeared protective, particularly among Black patients (OR 0.780, 95% CI 0.645-0.943). No significant associations were found for gender, pneumopathy, hepatopathy, nephropathy, diabetes, malignancy, or several laboratory and microbial factors.

Conclusions: Advanced age, cardiopathy, elevated creatinine, and Clostridium infection are significant mortality risk factors in NF. Race may have a protective effect. Further research is warranted to clarify the roles of other clinical and laboratory variables.