Postgraduate medicine最新文献

Background: Isolated sphenoid sinus fungal balls are a rare but clinically significant entity, often presenting with nonspecific symptoms. This case highlights the importance of multidisciplinary collaboration among different specialties to achieve optimal patient outcomes.

Case presentation: We report a case of a 29-year-old female presenting with recurrent pregnancy loss, referred by obstetrics for neurosurgical evaluation. Imaging revealed a giant sphenoid sinus fungal ball causing secondary hypopituitarism and infertility, a very rare complication. Subsequently, she was referred to ENT specialists, who did more imaging tests and removed the mass, leading to the restoration of pituitary function and pregnancy.

Conclusions: This case highlights the importance of considering sphenoid sinus pathology in patients with unexplained endocrine dysfunctions and the critical role of multidisciplinary collaboration in diagnosis and management. It also underscores the necessity of imaging the sphenoid sinus in patients with unexplained hyperprolactinemia and infertility, even in the absence of classic sinonasal symptoms. Early recognition and surgical intervention can lead to the resolution of symptoms and restoration of normal physiological functi[on, as demonstrated by the successful outcome in this patient.

Background: Agitation in Alzheimer's dementia has a substantial impact on patients, caregivers/family, and healthcare systems. As new evidence surrounding the treatment of agitation emerges, a roundtable of multispecialty experts convened to review published literature (from a PubMed database search on 1 October 2024) and provide evidence-based clinical practice consensus recommendations for the diagnosis and management of agitation in Alzheimer's dementia for US-based primary care providers.

Aim: The main objective of this article is to summarize key recommendations from the roundtable on identification, differential diagnosis, current clinical practice, nonpharmacologic interventions, pharmacologic interventions, and treatment and communication considerations for residential care facilities/home care settings and caregivers.

Results: Active communication between healthcare providers, patients, and caregivers/family is critical for early recognition, accurate diagnosis, and appropriate management and prevention of agitation. The foundation of treatment always begins with individualized psychoeducation and nonpharmacologic interventions based on the patient's personality, interests, and level of functioning. Pharmacologic interventions are strongly considered when agitated behaviors become highly intense, disturbing, and disruptive or if major safety concerns cannot be otherwise addressed, and only when the healthcare provider is confident that the agitation can be sufficiently managed or mitigated with a pharmacologic intervention possessing a favorable individual risk-benefit profile. While several pharmacologic agents have been studied in high-quality clinical trials for the treatment of agitation in Alzheimer's dementia, brexpiprazole is the only US Food and Drug Administration - approved treatment and it can be prescribed if warranted. Interventions should be continuously evaluated to optimize treatment and monitor and minimize potential side effects. A patient-centered approach that includes a strong partnership with caregivers/family as a vital part of the patient's larger care team is encouraged.

Conclusion: Following these recommendations for timely detection, accurate diagnosis, and appropriate management of agitation in patients with Alzheimer's dementia is likely to improve outcomes for most patients and caregivers.

Background: Ventricular arrhythmias (VA) are a major cause of sudden cardiac death (SCD) in heart failure patients. It is not known whether readily available clinical markers are of any clinical yield in detecting a subclinical inflammation that may be inflicted in acute arrhythmogenesis.

Aims: This study aimed to evaluate the prognostic value of inflammatory markers in patients undergoing ventricular tachycardia (VT) catheter ablation and to compare characteristics between those with electrical storm (ES) and elective ablation (EL).

Methods: This retrospective observational study included patients with structural heart disease undergoing VT ablation. Inflammatory markers (CRP, blood leukocyte, neutrophil, platelet, lymphocyte counts and systemic immune-inflammatory index (SII)) were assessed pre-procedurally. We analyzed procedural outcomes, VT recurrence, mid-term mortality and the presence of an electrical storm, correlating these with inflammatory markers. p < 0.05 was considered significant in all analyses.

Results: Of the 140 patients analyzed (median age 65 ± 15 years; 87.1% males), 63 (45%) had ES and 77 (55%) underwent elective ablation. The median ejection fraction was 25% ±15. The ES group had significantly higher neutrophil counts and systemic immune-inflammation index (SII) compared to the EL group (p = 0.010 and p = 0.013, respectively). On univariate analysis, elevated SII was associated with mid-term mortality (HR 3.487, p = 0.016), alongside age > 70 years and history of coronary artery bypass grafting (CABG). SII and history of CABG were independent predictors of death on multivariate analysis (HR 1.879, p = 0.018) and (HR: 4.891, p = 0.003), respectively.

Conclusion: SII is notably higher in those experiencing ES and is a predictor of mid-term mortality.

Background: The onset of arrhythmia during pregnancy has been noted as a significant issue in clinical management of adult congenital heart disease. The authors sought to examine the actual incidence of arrhythmias in CHD patients during pregnancy, as well as to distinguish prognostic predictors of arrhythmia in CHD pregnant patients, specifically focusing on the predictive value of echocardiographic parameters.

Methods: This retrospective study involved 244 pregnant patients with CHD in a tertiary hospital. Baseline characteristics and clinical presentation were systemically compared between the arrhythmia group and no arrhythmia group. Univariate analyses were performed to identify baseline characteristics and hemodynamic parameters associated with outcomes. Subsequent multivariate logistic regression model identified the adjusted odds ratio (aOR) and 95% CI to pinpoint the independent risk factors of arrhythmia in CHD pregnancy.

Results: The prevalence of arrhythmia in CHD patients during pregnancy was 17.6% (43/244). The arrhythmia group had more parity than the no arrhythmia group (0.72 vs 0.43, p = 0.010). Compared with the no arrhythmia group, the arrhythmia group's QRS duration was longer (105.1 ± 24.7 vs 93.6 ± 18.1 ms, p = 0.001). Patients with arrhythmia had both larger atrium size than patients without arrhythmia (right atrium: 51.0 ± 9.1 vs 47.4 ± 7.0 mm, p = 0.005; left atrium: 38.8 ± 7.6 vs 34.4 ± 4.8 mm, p = 0.000) respectively. Left ventricle end systolic volume in CHD patients with arrhythmia were considered larger than those without arrhythmia (29.9 ± 6.7 vs 27.7 ± 4.0 mm, p = 0.007), while not in left ventricle end diastolic volume (46.6 ± 9.2 vs 44.7 ± 5.2 mm, p = 0.067). The arrhythmia group were more likely to be presented with atrioventricular valve regurgitation (53.5% vs 15.4%, p = 0.000) than the no arrhythmia group. Multivariate logistic regression identified parity (aOR:1.895[95%CI: 1.033-3.478]), left atrium size (aOR:1.089[95%CI: 1.008-1.175]), and moderate atrioventricular valve regurgitation (aOR:3.317[95%CI: 1.272-8.647]) as independent contributors for arrhythmia during CHD pregnancy.

Conclusion: Early identification of risk factors that may predispose to arrhythmias favorably impacts long-term arrhythmia incidence and maternal neonatal outcome.

Objective: This pooled analysis of data from four randomized placebo-controlled trials summarizes the efficacy and safety of rimegepant for acute treatment of migraine.

Methods: In all studies, participants were aged ≥18 years and had a ≥ 1-year history of migraine, two to eight migraine attacks of moderate or severe pain intensity per month, and attacks lasting 4-72 hours if untreated. Participants were provided with a single dose of rimegepant 75 mg or placebo to treat a single migraine attack of moderate or severe pain intensity within the next 45 days. Co-primary endpoints at 2 hours post-dose were pain freedom and freedom from the most bothersome symptom (MBS). Treatment comparisons utilized Mantel-Haenszel risk estimation with stratification by study and prophylactic migraine medication use randomization stratum; p values are nominal. On-treatment adverse events (AEs) were also assessed.

Results: Overall, 4,895 participants received rimegepant (n = 2,439) or placebo (n = 2,456). For the co-primary endpoints, the proportion of participants with pain freedom 2 hours post-dose (20.0% vs. 11.8%; p < 0.0001) and MBS freedom 2 hours post-dose (40.2% vs. 29.2%; p < 0.0001) was higher in the rimegepant vs. the placebo group. Rimegepant also demonstrated improvements over placebo in nearly all secondary and exploratory efficacy endpoints. AEs were reported in 11.1% and 9.6% of participants in the rimegepant and placebo groups, respectively. The only AE reported in > 1% of participants was nausea (rimegepant = 1.4%, placebo = 1.3%). Severe AEs occurred in 0.3% and 0.1% of participants in the rimegepant and placebo groups, respectively. Serious AEs occurred in 0.1% of participants in both groups; none were deemed related to study treatment.

Conclusion: In this pooled analysis of four randomized placebo-controlled trials, a single dose of rimegepant 75 mg demonstrated efficacy and a favorable safety profile for the acute treatment of a migraine attack with moderate or severe pain.

Background: Cow's milk protein allergy (CMPA) is early life's most common food allergy. There is limited data on the development of respiratory allergies in childhood for infants with CMPA.

Objective: This study aimed to evaluate the development of respiratory allergic diseases in childhood according to the mechanism of CMPA in patients with CMPA in the first two years of life.

Methods: Patients who were diagnosed with CMPA in the first two years of life and were over five years old during the study period were included in the study. The sociodemographic, clinical, and laboratory data of patients were recorded, and the status of respiratory allergic disease development in patients was assessed using the ISAAC questionnaire.

Results: A total of 301 patients were included in the study; 182 (60.5%) were male. Most of the patients had mixed-type (87;28.9%) and had non-IgE-mediated (n:87;28.9%) CMPA. Of CMPA cases, 27.9% developed doctor-diagnosed asthma and 31.2% developed doctor-diagnosed allergic rhinitis. Doctor-diagnosed asthma was observed mostly with IgE-mediated CMPA (n:30;37%), and doctor-diagnosed allergic rhinitis was observed mostly with non-IgE-mediated CMPA (n:32;36.8%), and these differences were not statistically significant (p = 0.094, p = 0.385). Also, maternal asthma increased the risk of doctor-diagnosed asthma, while parental consanguinity, allergic rhinitis in mother/sibling, and paternal eczema were risk factors for doctor-diagnosed allergic rhinitis.

Conclusion: In this study, 27.9% of patients with CMPA in the first two years of life developed doctor-diagnosed asthma, and 31.2% developed allergic rhinitis. There was no difference in the frequency of occurrence based on the mechanism of CMPA development.

Objectives: This study aimed to assess the impact of a WHO-aligned intrapartum care model on labor aspects, including pain, fear, comfort, labor duration, oxytocin use, and perceptions of supportive care.

Methods: This is a randomized controlled study. The study was conducted with 124 primiparous pregnant women (intervention group n = 62, control group n = 62) who were admitted to the maternity unit of a hospital in Central Anatolia, Türkiye. The intervention group was subjected to the intrapartum care model, once cervical dilatation reached 5 cm. The control group received only standard intrapartum care in the hospital.

Results: The Visual Analog Scale (VAS) scores for the pregnant women in the intervention group who received intrapartum care in accordance with WHO recommendations were significantly lower than those for the control group (p < 0.001). The pregnant women in the intervention group exhibited lower fear of labor scores and higher comfort of labor scores during the active phase than those in the control group (p < 0.001). Furthermore, the duration of the first, second, and third stages of labor was observed to be significantly shorter in the intervention group compared to the control group (p < 0.001). Additionally, the use of oxytocin was found to be less prevalent in the intervention group compared to the control group (p < 0.001). Furthermore, the mean scores of the scale measuring women's perception of supportive care during labor were found to be significantly higher in the intervention group compared to the control group (p < 0.001).

Conclusion: In alignment with these findings, it is recommended that midwives and obstetricians implement the intrapartum care model in accordance with the World Health Organization's (WHO) recommendations. The implementation of this model aims to reduce labor pain, fear, and oxytocin use, enhance women's perception of birth comfort and care, and transform the birth experience into a more positive one.

Clinical trial registration: www.clinicaltrials.gov identifier NCT06681675.

Objectives: Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast. It is characterized by chronic inflammation and granuloma formation. We designed this study to assess the compliance and remission status of patients with IGM on methotrexate treatment.

Methods: The study included 114 patients who were treated with methotrexate for at least 1 year after a biopsy-proven diagnosis of IGM at a tertiary rheumatology center between January 2017 and February 2024. Demographic characteristics, clinical findings, laboratory parameters, treatment options and patient compliance with treatment were obtained from patient files.

Results: The mean age of patients diagnosed with IGM was 32.3 ± 6.3 years. Patients were treated with a combination of methotrexate, and complete remission was achieved in 97 patients (85.1%) after an average of one year. When Kaplan-Meier analysis was performed for the average annual methotrexate use, the average duration of drug use in patients with IGM was found to be 11.24 (10.88-11.49) months.

Conclusion: The use of methotrexate treatment in IGM patients has been shown to be both successful and well tolerated when evaluated according to the duration of drug administration.

Background: Upper airway surgery for obstructive sleep apnea (OSA) offers an alternative to CPAP, but its impact on weight changes is poorly studied.

Purpose: To systematically review published literature on the relationship between surgical intervention for OSA and changes in body mass index (BMI).

Methods: A literature search was conducted from 2013-2024 in five databases. Full-text English articles which examined BMI changes in adults with OSA pre- and post-surgery were included. The quality of each study was assessed independently by two researchers using the Newcastle-Ottawa Scale. This study was reported according to the PRISMA-ScR.

Results: Eleven studies, involving 406 patients from six countries were included. Most patients were males (88.4%) with a mean age of 40 years old. The pre-operative BMI were higher [27.8 kg/m² (SD = 2.6)] compared to a BMI of 27.7 kg/m² (SD = 1.3) at 21.0 months post-operation. The pre-operative Epworth Sleepiness Score was 13.28 (SD = 6.36), while the apnea-hypopnea index was 41.2 (SD = 16.88), indicating that most patients were diagnosed with severe OSA. The average oxygen desaturation index was 35.63 (SD = 11.17). The meta-analysis showed no significant BMI changes after surgery (mean difference:-0.29; 95% CI:-0.80 to 0.21; I² = 30%). Findings were consistent with no publication bias found.

Conclusions: Upper airway surgery for OSA does not significantly affect BMI. The authors propose closer monitoring of weight changes following upper airway surgery, as weight fluctuations can impact the outcomes of surgery. Unchanged weight post-surgery may be attributed to suboptimal OSA treatment.