The American journal of the medical sciences最新文献

Background: Drug-induced liver injury (DILI) plays an important role in liver failure and causes mortality. Patients with DILI compatible with Hy's law are associated with poorer outcomes. However, the predictive accuracy of Hy's law is not good enough in clinical practice. This study aimed to investigate the optimal values of biomarkers associated with the prognosis of DILI.

Methods: From June 1, 2014-May 30, 2022, patients with reported DILI were included. Patients' characteristics, drugs, DILI type, liver enzymes, and comorbidities were assessed. The associations with DILI-related comorbidities and survival were analyzed.

Results: Ninety-five DILI patients were enrolled, 5 patients died of liver failure, and 23 patients died within 56 weeks after DILI. This study found that 15 mg/dL of total bilirubin, 1000 U/L of ALT, and 2 of PT-INR were optimal cut-off values in predicting DILI-related mortality. For the overall survival, patients with sepsis (HR:5.053, 95% CI:1.594-16.018, p = 0.006), malignancy (HR:4.371, 95% CI:1.573-12.147, p = 0.005), or end-stage renal disease (HR:7.409, 95% CI:1.404-39.103, p = 0.018) were independent poor prognostic factors in multivariate Cox regression analysis.

Conclusions: Total bilirubin >15 mg/dL, ALT >1000 U/L, and PT-INR >2 are useful biomarkers in predicting DILI-related mortality. DILI patients with sepsis, malignancy, or end-stage renal disease are associated with worse overall survival.

Hypercalcemia has rarely been associated with seminomas. Due to the limited data available, the pathophysiology of hypercalcemia in seminoma has not been established in literature. We present a case of a 59-year-old male who presented with weakness, abdominal fullness, fatigue, constipation, and a 14 lb unintentional weight loss. On initial presentation he was found to be hypercalcemia with calcium of 16.2 mg/dL (normal 8.6-10.3 mg/dL). Subsequently, a metastatic seminoma was discovered with no evidence of bony metastasis. 1,25-dihydroxyvitamin D was elevated at >200 pg/mL (reference 19.9-79.3 pg/mL). PTH was suppressed at 11 pg/mL (reference 12-88 pg/mL). PTHrP was normal at 1.0 pmol/L (reference ≤4.2 pmol/L), 25‑hydroxy vitamin D was low at 22.6 ng/mL (reference 30-100 ng/mL), and phosphorus was normal at 3.9 mg/dL (reference 2.4-4.9 mg/dL). These findings indicate 1,25-dihydroxyvitamin D mediated hypercalcemia of malignancy. Hypercalcemia in seminoma has been reported in 11 cases, that we review in this report. However, few cases present sufficient data to conclude the pathophysiology of hypercalcemia. In all four cases that presented 1,25-hydroxyvitamin D levels, the levels were elevated, suggesting seminomas are associated with 1,25-hydroxyvitamin D mediated hypercalcemia. Interestingly, one case was associated with increased 1,25-hydroxyvitamin D and increased PTHrP levels, suggesting there may be multiple mechanisms of hypercalcemia in seminomas.

Data from pivotal randomized controlled trials established the four pillars of guideline-directed medical therapy in heart failure with reduced ejection fraction. The randomized controlled trials enrolled stable patients with New York Heart Association functional class II-III and a low incidence of cardiovascular death and hospitalization for heart failure. Whether the four pillars retain therapeutic value when a patient's symptoms worsen and life expectancy decreases has received scarce attention. We review the observational studies that point to the fading benefit of neurohormonal modulation and cardiac afterload reduction in the late stages of cardiovascular or renal diseases. We then propose a pragmatic approach for collecting evidence-based data on sequential withdrawal of the four pillars in patients with heart failure and reduced ejection fraction after years of guideline-directed medical therapy.

Primary pulmonary lymphoma (PPL) is a rare type of lymphoma, representing <1% of all primary lung cancers. Mucosa associated lymphoid tissue (MALT) lymphoma, the most common type of PPL, has an indolent slow growing course over years leading to frequent misdiagnoses. We report a similar case of a 45 years-old-man with a protracted course of intermittent cough and dyspnoea, masquerading as recurrent pneumonia over 10 years. A dig into his prior records revealed consolidation of right lower lobe that had slowly progressed to involve other lobes with new cavitation. A transthoracic biopsy confirmed it as MALT lymphoma. This case highlights the unusual manifestation in MALT lymphoma (being in disguise for a decade prior to diagnosis), thus emphasizing the role of meticulous evaluation of prior medical records and biopsy.

Background: The American Heart Association recently defined cardio-kidney-metabolic (CKM) syndrome as the intersection between metabolic, renal, and cardiovascular disease. Understanding the contemporary estimates of CKM related mortality in the US is essential for developing targeted public interventions.

Methods: We analyzed state-level and county-level CKM-associated all-cause mortality data (2010-2019) from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER). Median and interquartile (IQR) age-adjusted mortality rates (aaMR) per 100,000 were reported and linked with a multi-component metric for social deprivation: the Social Deprivation Index (SDI: range 0 - 100) grouped as: I: 0 - 25, II: 26 - 50, III: 51 - 75, and IV: 75 - 100. We fit pairwise comparisons between SDI groups and evaluated aaMR stratified by sex, race, and location.

Results: In 3101 counties, pooled aaMR was 505 (441-579). Oklahoma (643) and Massachusetts (364) had the highest and lowest values. aaMR increased across SDI groups [I: 454(404, 505), IV: 572(IQR: 495.9, 654.7); p < 0.001]. Men had higher rates [602 (526, 687)] than women [427 (368, 491)]. Metropolitan [476 (419, 542)] had lower rates than non-metropolitan counties [521 (454, 596)]. Non-Hispanic Black [637 (545, 731)] had higher rates than non-Hispanic White residents [497 (437, 570]. CKM associated aaMR remained reasonably constant between 2010 and 2019 (Mann Kendall test for trend p-value = 0.99).

Conclusions: In the US, CKM mortality disproportionately affects more socially deprived counties. Inability to reduce CKM mortality rates over the study period highlights the need for targeted policy interventions to curb the ongoing high burden.

Objective: The study aimed to investigate the impact of varying thyroid function statuses on clinical and laboratory indicators in patients with systemic lupus erythematosus (SLE).

Methods: A retrospective analysis was conducted on 258 patients with SLE, who were stratified according to thyroid function, renal involvement, and disease activity. The predictive value of thyroid hormones was evaluated using a receiver operating characteristic (ROC) curve.

Result: Among the 258 patients with SLE, 141 were classified as the normal group, while 117 exhibited thyroid hormone abnormalities, categorized into hypothyroidism (N=112) and hyperthyroidism (N=5) groups. Serum levels of FT3 and FT4 positively correlate with total protein and albumin, while negatively correlating with the SLE Disease Activity Index 2K (SLEDAI-2K) and 24-hour urinary protein (24hUP) (P<0.05). Compared to individuals without renal involvement, those with renal involvement exhibited lower levels of FT3 and FT4 (3.35±0.99 vs. 4.07±2.22, 12.92±3.14 vs. 14.63±3.39, P=0.001), along with elevated thyroid-stimulating hormone (TSH) levels (7.08±14.40 vs. 5.28±12.48, P=0.343). The subgroups in euthyroid (n=86) and hypothyroid (n=93) of SLE patients with renal involvement exhibited different characteristics (P<0.05). The levels of FT3 gradually decreased with increase of disease activity. The areas under the ROC curve of FT3, FT4, TSH and their combination were 0.651, 0.654, 0.643, 0.669, respectively (P<0.05).

Conclusions: The correlation between thyroid function and the severity of SLE is significant, SLE patients with hypothyroidism exhibit more pronounced disease manifestations and an elevated risk of organ damage. SLE patients with low levels of FT3 and FT4 are prone to progressing to nephritis.

Background: Patients with combined pulmonary fibrosis and emphysema (CPFE) may experience emphysema or fibrosis progression on chest computed tomography (CT). This study aimed to investigate the relationship and prognosis in CPFE patients with emphysema or fibrosis progression.

Methods: A total of 188 CPFE patients were included in our retrospective cohort study. The clinical presentations, radiographic features, and laboratory findings of the patients were reviewed.

Results: Among CPFE patients, 28.1% exhibited emphysema progression and 43.3% showed fibrosis progression. Different higher tumour markers were observed in the emphysema or fibrosis progression groups. Smoking, definite usual interstitial pneumonia (UIP), and total extent of emphysema were risk factors for emphysema progression. Age, definite UIP, and mediastinal lymph node enlargement were risk factors for fibrosis progression. Patients with fibrosis progression had worse prognoses than patients without fibrosis progression (HR 2.159; 95% CI, 1.243-3.749; P = 0.006). However, the prognosis was similar between patients with and without emphysema progression (HR 0.839; 95% CI, 0.429-1.641; P = 0.608). There was no significant interaction between emphysema and fibrosis progression (p > 0.05).

Conclusions: In CPFE patients, emphysema and fibrosis progression had different higher tumour markers, risk factors, and prognosis effects. There was no significant interaction between emphysema and fibrosis progression. Fibrosis progression had a deleterious effect on prognosis, whereas emphysema progression did not affect prognosis. Therefore, the primary objective of CPFE treatment should be to halt or even reverse the progression of fibrosis. CPFE may be primarily a fibrotic disease, with emphysema being an incidental complication.

Cancers of the oral cavity, lip, salivary gland, and oropharynx cause substantial global disease burden. While tobacco-use and alcohol use are highly associated with oral cancers, the rising incidence of disease in patients who do not use tobacco or alcohol points to additional carcinogenic risk factors. Chronic inflammation, disruption of the oral microbiome, and dysbiosis are becoming more widely implicated in the pathogenesis of oral cancer. Several studies have identified specific bacterial species enriched in patients with oral cancer, including Porphyromonas gingivalis and Fusobacterium nucleatum. In this narrative review, we describe potential carcinogenic mechanisms exhibited by these species and other microbes in the development of oral cancer.

Background: Catheter-directed interventions (CDIs) for pulmonary embolism (PE) continue to evolve. However, due to the paucity of data, their use has been limited in patients with underlying kidney disease.

Methods: The National Readmission Database (2016-2020) was utilized to identify intermediate to high-risk PE (IHR-PE) patients requiring CDI (thrombectomy, thrombolysis, and ultrasound-assisted thrombolysis). Cohorts were stratified based on the presence of CKD stage ≥3, including ESRD. A Propensity Score Matching (PSM) model was applied to compare outcomes.

Results: From 2016-2020, 20795 patients with IHR-PE underwent CDIs. Most were done in the non-CKD/ESRD population (N:18438, 88.7 %), while only 2357 (11.3 %) were done in the CKD/ESRD population. After propensity matching, the CKD/ESRD population had higher adverse events, including mortality (7.3 % vs. 5.1 %, p: 0.036), need for transfusions (52.6 % vs. 44.7 %, p < 0.001), and acute bleeding (15.4 % vs. 10.6 %, p < 0.001). CKD/ESRD population had a higher median LOS (5 vs. 4 days, p < 0.001) and total cost ($32935 vs. $29805, p < 0.001) in the index admission. Over the study period, total cost decreased in the CKD/ESRD population ($37829 to $31436, p-trend: 0.024) but remained the same in the non-CKD/ESRD population (p-trend>0.05). 180-day readmission rates were higher in the CKD/ESRD population (24.7 % vs. 17.5 %, p: 0.006). Our subgroup analysis, excluding ESRD patients, showed no significant difference in in-hospital mortality (6.5 % vs. 7.3 %, p > 0.05), but the rates of thoracic or respiratory bleeding (4.5 % vs. 2.6 %, p:0.012), need for transfusions (52.4 % vs.. 43.5 %, p < 0.001), and AKI (57.1 % vs. 23.2 %, p < 0.001) were higher in patients with CKD undergoing CDIs for IHF-PE.

Conclusion: CKD/ESRD patients requiring catheter-directed interventions for IHR-PE had higher periprocedural mortality and acute bleeding. The presence of ESRD mainly drove periprocedural mortality in our study, while the presence of non-dialyzed CKD was associated with higher rates of non-fatal localized hemorrhage.