Journal of clinical medicine research最新文献

Remimazolam is an ultrashort-acting benzodiazepine, approved for clinical use by the United States Food & Drug Administration in 2020. Similar to other benzodiazepines, its clinical effects of sedation, anxiolysis, and amnesia are mediated through the gamma-aminobutyric acid A (GABA_A) receptor. A unique metabolic pathway via tissue esterases results in a rapid elimination, a limited context-sensitive half-life, and prompt dissipation of its effect when administration is discontinued. Preliminary clinical experience has demonstrated its efficacy in the adult and pediatric population as a primary agent for procedural sedation or as an adjunct to general anesthesia. Given its rapid onset and recovery, preliminary clinical experience has demonstrated its potential utility in neuroanesthesia including procedural sedation for neuroimaging as well as a primary agent and adjunct for general anesthesia during neurosurgical procedures including awake craniotomy. This narrative review outlines the pharmacological properties of this unique medication, reviews previous published reports of its role in neuroanesthesia and neurocritical care, and discusses dosing parameters and clinical use in this population.

Background: Hyperglycemia is commonly encountered in the Emergency Departments, necessitating the differential diagnosis between diabetic ketoacidosis (DKA) and simple hyperglycemia, as the treatment and prognosis differ significantly. In clinical practice, it is essential to investigate DKA in all patients; however, the final diagnosis of actual DKA is found in only 1-5% of these cases, resulting in unnecessary costs. This study aimed to develop an application for predicting the probability of DKA in patients with capillary blood glucose levels exceeding 250 mg/dL in the Emergency Department.

Methods: This study was conducted as diagnostic prediction research, employing a retrospective observational delayed-type cross-sectional design. Data were collected from patients with capillary blood glucose levels exceeding 250 mg/dL between January and April 2023. The predictive variables were available at the time of prediction. Analysis was performed using multivariable risk ratio regression analysis, with results reported as multivariable risk ratios. The area under the receiver operating characteristic (AuROC) curve was calculated. Internal validation was performed using bootstrapping and calibration plots. An application named "1-DKA Alert" was developed to predict the probability of DKA for use in real-world clinical settings.

Results: The study included 274 adult patients, of whom 52.9% were female, with an average age of 59 years. Predictive factors for DKA included initial capillary blood glucose, type of diabetes mellitus, insulin usage, poor compliance, respiratory rate, and suspected infection. These variables were readily available in clinical practice and yielded an AuROC of 0.8777 (95% confidence interval (CI): 0.8294 - 0.9259). Bootstrapping internal validation demonstrated an AuROC of 0.8770 and a shrinkage factor of 0.991.

Conclusions: The "1-DKA Alert" demonstrates excellent discriminative ability, and the model is valid, suggesting its potential for use in clinical practice. However, further studies for external validation are necessary.

Renovascular hypertension (RVHT) is most commonly caused by renal artery stenosis (RAS) secondary to arteriosclerosis. Other causes of RVHT include fibromuscular dysplasia (FMD) and other rare causes, such as Takayasu arteritis (TA). A male patient in his early 20s presented with hypertension. Laboratory findings were positive for hypokalemia as well as elevations in plasma renin activity and aldosterone concentration. Plain computed tomography revealed atrophy of the right kidney, and magnetic resonance angiography revealed right RAS. A diagnosis of RVHT was suspected, and he was admitted to the cardiovascular ward. After percutaneous transluminal renal angioplasty (PTRA) to treat the right RAS, a typical course was observed with decreased blood pressure, normalizing hypokalemia, and decreased plasma renin activity and aldosterone concentration (which previously were extremely elevated). As angiography showed no remarkable arteriosclerosis of other vessels and given the patient's young age, FMD was suspected as the underlying cause of RVHT. However, the angiographic findings of RAS in the proximal renal artery and the lack of "string-of-beads" appearance were atypical for FMD. The patient had chronic inflammation, and further investigation revealed severe stenosis of the right carotid artery. The high C-reactive protein value and the thickened aortic wall in the computed tomography were the suggestive signs for TA. The patient was diagnosed with TA and started on steroid therapy. Although moderate stenosis remained after revascularization of the renal artery in this patient, hypertension improved markedly, demonstrating the effectiveness of PTRA. Given the diagnosis of TA as the underlying disease, the likelihood of recurrent RVHT due to restenosis of the renal artery remains high, and strict follow-up is thus required.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a progressive neurological disorder characterized by weakness and impaired sensory function due to damage to peripheral nerves. Evaluating grasp function is critical for understanding the impact of CIDP on patients' daily activities and guiding rehabilitation strategies. This comprehensive review examines the role of dynamometers in quantifying grip strength deficits, tracking disease progression, and assessing treatment outcomes in CIDP patients. Key findings highlight the utility of dynamometers in quantifying grip strength deficits, tracking disease progression, and evaluating treatment outcomes. The review also explores methodological considerations, such as standardizing testing protocols and integrating dynamometric measurements with clinical scales. By providing insights into the functional impairments associated with CIDP and the effectiveness of therapeutic interventions, this review underscores the role of dynamometry in advancing patient care and enhancing the quality of life for individuals living with this condition. Future research directions include the development of more sensitive dynamometric tools and longitudinal studies to better understand the relationship between grip strength and overall disease trajectory in CIDP.

Background: Ascorbic acid is a strong antioxidant that prevents postoperative delirium by inhibiting reactive oxygen species production. This pilot study was designed to investigate the prevalence of postoperative delirium among older patients undergoing cardiovascular surgery, who received perioperative ascorbic acid administration, to estimate an appropriate sample size for further randomized controlled trials.

Methods: This single-arm prospective interventional study enrolled patients aged > 70 years scheduled to undergo elective cardiovascular surgery using cardiopulmonary bypass. Ascorbic acid (500 mg) was administered intravenously every 6 h for a total of eight times following the induction of general anesthesia. The incidence of postoperative delirium was evaluated until discharge using the Confusion Assessment Method for the Intensive Care Unit.

Results: Data from 48 patients were analyzed. Of the 48 patients, 16 developed postoperative delirium (33.3%). Patients in the delirium group had more severe heart failure (New York Heart Association Classification), higher European System for Cardiac Operative Risk Evaluation scores, lower intraoperative Bispectral Index, longer duration of cardiopulmonary bypass and surgery, incidence of postoperative cerebral infarction, longer intubation time, and length of intensive care unit stay.

Conclusions: The incidence of postoperative delirium among older patients undergoing cardiovascular surgery who received ascorbic acid perioperatively (2 g/day for 2 days) was 33%. This incidence was comparable to that observed in a previous observational study, suggesting that ascorbic acid administration may not be effective in preventing the incidence of postoperative delirium.

Background: The aim of the study was to determine whether treatment with oral pulmonary arterial hypertension (PAH)-targeted therapy is associated with functional or hemodynamic improvement in patients with pulmonary hypertension due to interstitial lung disease (PH-ILD).

Methods: We conducted a retrospective review of 1,507 consented patients with pulmonary hypertension (PH) from the University of Chicago PH Registry. Exclusion criteria included: enrollment in PH-related clinical trials, use of inhaled treprostinil or iloprost and prior PAH-targeted therapy initiated before consenting to registry enrollment, thus precluding baseline data. Data analyzed included demographics, interstitial lung disease (ILD) classification, PAH-targeted therapy, functional data, hemodynamics, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) before and after initiation of treatment. Data were analyzed using paired t-test, or related-samples Wilcoxon signed rank test.

Results: Of 37 patients included, 27 (73%) received treatment with one PAH-targeted therapy and nine (24%) received dual therapy. At baseline, median NT-proBNP was 1,498 ng/dL (675 - 3,208), mean pulmonary artery pressure (mPAP) was 45 ± 11 mm Hg, and pulmonary vascular resistance (PVR) of 9 ± 4 Wood units (WU). In patients with measurements both before and after treatment with PAH-targeted therapy, there was a decrease in PVR (n = 13, 8 vs. 5 WU, P < 0.001), an increase in cardiac output (n = 13, 4 vs. 5 L/min, P = 0.014), and a decrease in NT-proBNP levels (n = 26, 1,421 vs. 842 ng/dL, P = 0.045).

Conclusions: In this study, use of PAH-targeted therapy in patients with PH-ILD was associated with statistically significant and clinically meaningful improvements in NT-proBNP and pulmonary hemodynamics.

Background: The study evaluated the effect of an acute and a 2-week daily repetitive ischemic preconditioning (IPC) on conduit artery vascular function and thrombogenic clotting profile, in patients with a recent ischemic stroke.

Methods: Fourteen patients, aged 71 ± 8 years, with a cerebral small vessel occlusion stroke were included in a randomized, controlled, open-label cross-over study. Treatment consisted of 2 weeks of daily IPC, four 5-min rounds of upper-arm occlusion, interspersed by 5 min rest periods. Control was without treatment. Brachial artery flow-mediated dilation (FMD) was determined at baseline and after the control and treatment periods. Before and after each period, the patients underwent an acute bout of IPC. Blood samples were obtained for thrombogenic clotting profile at baseline and after the acute IPC bout, both before and after the control and treatment periods.

Results: The period of daily IPC increased brachial artery diameter but did not influence FMD. Acutely, IPC was found to induce an increase in fractal dimension, indicating a denser clot microstructure, and a reduction in plasma levels of plasminogen activator inhibitor 1 (PAI-1). There was no effect of daily IPC on the basal thrombogenic clotting profile, or on the change in clotting profile induced by acute IPC.

Conclusions: Collectively, the data show that acute IPC leads to a prothrombotic clotting profile, despite antiplatelet therapy. Moreover, 2 weeks of daily treatment with IPC does not influence conduit artery vascular function or thrombogenicity in stroke patients.

Background: Disuse osteoporosis in hemiparetic patients often results in significant morbidity, decreased quality of life, and different clinical characteristics. The study aimed to investigate the effect of these clinical factors on bone mineral density (BMD).

Methods: This was an analytical observational study with a cross-sectional method evaluating hemiparetic patients at Cipto Mangunkusumo Hospital from 2018 to 2019. BMD (g/cm²) was assessed using dual energy X-ray absorptiometry (DXA) on the spine and both sides of the body. The relationship and correlation between BMD and delta BMD scores with clinical characteristics were analyzed. A linear regression test was used to assess the correlation between variables.

Results: A total of 34 participants were recruited for this study. There was a difference between the healthy and paretic side of BMD of both hip and wrist (P < 0.001), strong positive correlation between the onset of hemiparesis and wrist and hip delta BMD (r = 0.779, P = 0.001 and r = 0.791, P = 0.001), and significant association between delta BMD and age and motor strength. Multivariate analysis shows that the onset of hemiparesis was a strong predictor of delta BMD (aR² wrist = 0.486, aR² hip = 0.614). There was a 7.36% decrease in the mean BMD score of the paretic side compared to the non-paretic side.

Conclusion: A low BMD score is prevalent in seven out of 10 patients with post-stroke neuromuscular deficit. Age, limb strength, the onset of hemiparesis, and rehabilitation compliance are associated with decreased BMD among patients with post-stroke neuromuscular deficit.

Background: Metformin is a commonly prescribed oral hypoglycemic agent for diabetic patients. Its effect in reducing the incidence of stroke has already been proven. We aimed to explore the impact of prior metformin use on stroke outcomes.

Methods: The Web of Science, PubMed, Embase, and Cochrane Library were searched to identify relevant studies involving stroke patients with a history of metformin use and comparing them to non-metformin users. We analyzed the following outcomes: modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), mortality, or length of hospitalization.

Results: Eleven studies, with 13,825 participants, were included. The metformin group showed higher favorable mRS 0 - 2 than the non-metformin group (risk ratio (RR) = 1.14, 95% confidence interval (CI): 1.09 - 1.19, P value < 0.01). Also, significantly lower mortality rates were seen in the metformin group (RR = 0.54, 95% CI: 0.46 - 0.63, P value ≤ 0.01). NIHSS at discharge was lower in the metformin group than the non-metformin group (mean difference (MD) = -0.46, 95% CI: -0.82 - -0.11, P value < 0.01). The mRS 3 - 6 indicates less favorable outcomes were higher in the non-metformin group (RR = 0.85, 95% CI: 0.77 - 0.93). At the same time, NIHSS at admission showed no statistically significant difference between the two groups. These results indicate that metformin has a beneficial impact on the severity of stroke.

Conclusions: Pre-stroke metformin therapy is associated with better post-stroke clinical outcomes and lower mortality rates. These results highlight the potential neuroprotective role of metformin and emphasize its role as an adjunctive treatment in stroke management. Further research is required to understand its mechanism better.

Background: Alloimmunization presents a significant challenge for patients with β-thalassemia major who depend on regular transfusion therapy. This systematic review and meta-analysis aimed to evaluate the frequency of alloimmunization within the Rhesus blood group system and identify the most prevalent alloantibodies.

Methods: A comprehensive search across multiple databases was conducted to locate epidemiological studies reporting alloimmunization in thalassemia patients undergoing repeated transfusions, specifically focusing on Rhesus antibodies. Statistical analyses were performed using R software, and heterogeneity was assessed using I² statistics.

Results: This review included 20 studies with a total of 4,650 patients. The overall prevalence of alloimmunization was 5.4% (95% confidence interval (CI): 3.1-9.3%) across all ages, with a prevalence of 9.1% (95% CI: 5.3-15.2%) in children and 25% (95% CI: 12.7-41.2%) in adults. The pooled overall prevalence was 6.6% (95% CI: 4.2-10.2%). Among the 488 alloimmunized patients, 310 developed Rhesus-specific antibodies, with anti-E (34.58%) and anti-D (13.69%) being the most frequent.

Conclusions: This study underscores the substantial prevalence of Rhesus antibodies among alloimmunized thalassemia patients. Implementing extended phenotype matching for transfusions could significantly reduce the risk of alloantibody formation in this population. Future analyses should explore factors influencing alloimmunization rates, such as ethnic diversity, matching protocols, and age-related variations, to inform clinical practice better.