Journal of clinical medicine research最新文献

Background: Ventilator-associated pneumonia (VAP) caused by multidrug-resistant (MDR) Gram-negative bacteria has presented significant treatment challenges in critical care. While intravenous colistin is commonly used, its nephrotoxicity and limited lung penetration raise concerns. This study aimed to compare the clinical efficacy and safety of aerosolized versus intravenous colistin in patients with VAP.

Methods: The study included 60 adult patients diagnosed with VAP caused by colistin-sensitive MDR Gram-negative bacteria. Treatment decisions (aerosolized or intravenous colistin) were made by attending physicians based on clinical judgment (n = 30 per each group). The primary outcome was clinical success; secondary outcomes included time to defervescence, Clinical Pulmonary Infection Score changes, and adverse events.

Results: Clinical success was achieved in 80.0% of patients in the aerosolized group compared with 70.0% in the intravenous group (P = 0.38). The time to defervescence was significantly shorter in the aerosolized group (3.0 ± 1.2 days) than in the intravenous group (5.0 ± 1.7 days; P = 0.002). Nephrotoxicity occurred in 13.3% of patients receiving aerosolized colistin and in 23.3% of those receiving intravenous colistin (odds ratio (OR) 0.51; 95% confidence interval (95% CI) 0.13-2.03; P = 0.19). Microbiological clearance was observed in 66.7% of the aerosolized group and 56.7% of the intravenous group (P = 0.44). Intensive care unit mortality was 16.7% in the aerosolized group and 23.3% in the intravenous group (P = 0.52).

Conclusion: Aerosolized colistin was feasible and generally well tolerated; however, these findings should be interpreted as descriptive and hypothesis-generating, and further studies are needed to confirm their clinical relevance.

Background: Psychopathological manifestations are key features of long COVID, contributing to a considerable global mental health burden. Neuropsychiatric sequelae such as anxiety, depression, cognitive dysfunction, and perceived stress may persist for months or years after infection. Latin American populations remain underrepresented, despite a high prevalence of long COVID and unique socio-demographic characteristics. Understanding these impacts is essential for targeted screening and interventions.

Methods: We conducted a prospective study of patients hospitalized for severe COVID-19. Psychiatric evaluation used the General Anxiety Disorder-7, Patient Health Questionnaire-9, Perceived Stress Scale-14, and Addenbrooke's Cognitive Examination-III (ACE-III), at an average of 24.5 months post-illness. Bivariate analyses evaluated differences by sex and intensive care unit (ICU) admission. Multivariable linear regression was used to examine associations between cognitive scores and age, sex, education, socioeconomic status, ICU admission, body mass index, smoking exposure, hypertension, and diabetes.

Results: We included 152 patients; the mean age was 56 years, and 58.5% were male. Anxiety symptoms were present in 33%, depression in 49%, and both perceived stress and cognitive dysfunction were each observed in 11% of patients. Women exhibited significantly higher levels of depression (P = 0.02) and stress (P = 0.011), whereas patients admitted to the ICU demonstrated greater cognitive impairment (P < 0.001). In multivariable regression, male sex (P = 0.002), higher education (P < 0.001), and hypertension (P = 0.037) were significantly associated with higher ACE-III scores, while ICU admission was associated with lower scores (P = 0.017).

Conclusion: Our study reveals a high prevalence of mental health symptoms and cognitive dysfunction among patients 2 years after severe COVID-19. Anxiety showed no differences by sex or ICU requirement. Women exhibited higher rates of depression and perceived stress, while ICU admission was associated with poorer cognitive performance. Our findings should encourage systematic screening, diagnosis, and management of long-term neuropsychiatric sequelae in COVID-19 survivors. However, due to the limitations of the single-center design, further longitudinal and multicenter studies are warranted to better elucidate the long-term psychiatric impact of COVID-19.

Background: Hypernatremia is a common complication among neurocritical care patients. This study aimed to investigate the effectiveness and safety of regional citrate anticoagulation (RCA) vs. no anticoagulation (NA) in neurocritical patients receiving continuous renal replacement therapy (CRRT) who also had chronic severe hypernatremia and an elevated risk of bleeding.

Methods: From March 2020 to August 2024, electronic medical records of neuro-critically ill patients who underwent CRRT for chronic severe hypernatremia with elevated risk of bleeding at Henan Provincial People's Hospital's neurocritical intensive care unit (ICU) were retrospectively analyzed. Patients were divided into RCA (n = 70) and NA (n = 28) groups. The key effectiveness objective was the mean serum sodium correction, while the primary safety event was the occurrence of common anticoagulant adverse events. Original cohorts were matched using propensity score matching (PSM) between two groups (n = 21). Risk factors impacting the initial filter lifespan were analyzed using Cox proportional risk regression model.

Results: Both groups achieved similar sodium correction rates (0.5 ± 0.1 mmol/L/h). The RCA group had a lower incidence of both hemorrhagic (6/70 (8.6%) and 8/28 (28.6%), P = 0.021) and filter coagulation (0/70 (0%) and 17/28 (60.7%), P < 0.001) adverse events. After performing Kaplan-Meier curve and multivariable Cox regression, RCA was identified as an independent protective factor for first filter lifespan (hazard ratio (HR) = 0.09, 95% confidence interval (CI), 0.05-0.18).

Conclusion: RCA is safer and equally effective as NA for CRRT in neurocritical patients with chronic severe hypernatremia, reducing bleeding and filter clotting risks. While our retrospective study suggests that RCA is a safe and effective strategy in this population, the findings require validation in a large-scale, randomized controlled trial to establish conclusive evidence.

Background: Breast cancer is the leading cause of cancer death in women worldwide. Breast imaging, usually mammography and/or ultrasound, is classified using the Breast Imaging-Reporting and Data System (BI-RADS). At Lampang Hospital, mammography delays of up to 5 months postpone diagnosis in 40% of breast cancer cases. An urgent queue for palpable breast masses was introduced, but nearly half were benign, leading to inefficient prioritization. This study aimed to develop a two-step model based on high-risk ultrasound features and compare it with reference BI-RADS classifications.

Methods: This diagnostic prediction study collected retrospective data from Lampang Hospital between January 2021 and December 2023. Ultrasound images of 390 patients were independently reviewed by radiologists blinded to the reference BI-RADS classification. Stepwise multivariable risk difference regression analysis was applied to identify predictive characteristics from seven predefined ultrasound findings.

Results: Three predictive characteristics were identified: shape, margin, and echo pattern. The two-step model showed excellent discrimination, with an area under the receiver operating characteristic curve (AuROC) of 0.9801 (95% CI, 0.9696-0.9907) in step 1 and 0.9623 (95% CI, 0.9411-0.9835) in step 2. Internal validation with 200 bootstrap cycles confirmed minimal optimism. Using prevalence-based cut points, the model achieved 88.5% accuracy, with 6.7% underestimation in BI-RADS 4-5 (predicted as 3) and overestimation not exceeding 3% in any category.

Conclusions: A two-step ultrasound-based model using shape, margin, and echo pattern demonstrated excellent discrimination as well as high accuracy, with slightly increased underestimation and minimal overestimation. This re-scheduling strategy optimizes mammography queue prioritization, but external validation is required before clinical implementation.

Background: Endometrial stromal tumors (ESTs) represent a heterogeneous group of uterine mesenchymal neoplasms with variable clinical outcomes. Although histological grading is a cornerstone for prognosis, the contribution of proliferative and immune microenvironment markers remains incompletely defined.

Methods: We retrospectively analyzed 90 patients diagnosed with endometrial stromal nodule (ESN) (n = 30), low-grade endometrial stromal sarcoma (LG-ESS, n = 30), and high-grade endometrial stromal sarcoma (HG-ESS, n = 30) between 2017 and 2025 across 35 public and private clinics in four Georgian cities. All specimens underwent standardized immunohistochemistry for estrogen receptor (ER), progesterone receptor (PR), Ki67, cyclinD1, cyclin-dependent kinase 4 (CDK4), CD117, forkhead box P3 (FOXP3), CD163, and CD34. Disease-free survival (DFS) was calculated from date of surgery to recurrence/metastasis. Kaplan-Meier curves and log-rank tests were used to assess survival differences, and data-driven cutoffs (Youden index) were employed to stratify biomarker expression. Multivariable Cox proportional hazards regression was applied to identify independent predictors of recurrence.

Results: Median follow-up was 55 months. DFS significantly differed by histology: not reached for ESN, 20.0 months for LG-ESS, and 5.0 months for HG-ESS (log-rank P < 0.0001). High Ki67, cyclinD1, CDK4, CD117, FOXP3, and CD163 predicted shortened DFS, while ER/PR expression correlated with prolonged DFS (all P < 0.0001). In adjusted models, lymphovascular space invasion (LVSI) (odds ratio (OR): 3.59, 95% confidence interval (CI): 3.21 - 3.87), Ki67 (OR: 4.65, 4.08 - 5.10), tumor necrosis (OR: 2.39, 2.06 - 2.79), cyclinD1 (OR: 2.20, 1.99 - 2.43), and CD163 (OR: 2.06, 1.72 - 2.51) remained independently associated with recurrence.

Conclusions: Beyond histological grade, proliferative signaling and M2 macrophage polarization strongly influence recurrence risk in ESS. These findings highlight potential diagnostic and therapeutic targets, suggesting integration of immune and cell-cycle biomarkers into future risk stratification models.

Background: Impaired social functioning is one of the core symptoms of schizophrenia (SCZ). Genetic factors have also been implicated in SCZ. To contribute to the discussion on the involvement of genetic factors in SCZ, we evaluated the social functioning of first-degree relatives (FR) of patients with SCZ.

Methods: This was a non-interventional observational study. We examined social functioning using the Japanese version of the Social Functioning Scale (SFS-J) in three groups: SCZ, SCZ FR, and healthy controls (HC). The effects of the groups (SCZ, FR, and HC) on social functioning were evaluated using analysis of covariance. In addition, the cutoff value for SCZ in the SFS total score was calculated, and the trend in the proportion of individuals below the cutoff value in each group was evaluated.

Results: Data from 256 subjects (SCZ (n = 44), FR (n = 26), and HC (n = 186)) were analyzed. Group, years of education, intelligence quotient (IQ), and sex were found to be significant factors affecting SFS total scores. The proportion of SFS scores < 140 (the cutoff value for SCZ) was 9.1% in HC, 57.7% in FR, and 95.4% in SCZ, showing a continuous increase in the proportion of SFS scores < 140 across the three groups (P < 0.0001).

Conclusions: In social functioning assessed by SFS, the score for FR was intermediate between those of SCZ and HC. The results of this study suggest that genetic factors may influence social functioning scores in SCZ and FR.

Background: Graft-versus-host disease (GvHD) is a serious complication of allogeneic hematopoietic cell transplantation, and the major cause of post-transplant mortality and morbidity. If steroid treatment as first-line therapy fails, treatment options are limited. Ruxolitinib (Ruxo) as well as extracorporeal photopheresis (ECP) showed high efficacy in the treatment of steroid-refractory (SR) acute and chronic GvHD.

Methods: We interrogated data from 68 adult and pediatric patients with SR acute and chronic GvHD, between 2017 and 2024, who received either Ruxo plus ECP (Ruxo + ECP, n = 31) or Ruxo alone (Ruxo, n = 37). Endpoints were to compare the overall response rates (ORRs) including complete response (CR) and partial response (PR) of acute and chronic GvHD at last encounter, and the percentage of patients with history of acute GvHD, who progressed to chronic GvHD at 1 year, 1-year non-relapse mortality (NRM), graft-versus-host disease relapse-free survival (GRFS) and survival outcomes at 3 years.

Results: Patient, disease, and transplant characteristics were well balanced, except for more severe acute GvHD in Ruxo + ECP arm (66.6% vs. 18.5%, P = 0.007) and longer Ruxo treatment in Ruxo alone arm (11 vs. 7 months, P = 0.05). The ORRs were 58% for Ruxo + ECP arm compared to 49% in Ruxo alone arm (P = 0.002) at last encounter and the duration of response was 17.6 versus 9 months (P = 0.3171), respectively. In both arms, 87% and 93% of patients could taper steroids rapidly by 50% and 16%. At 1 year, cumulative incidence of chronic GvHD was higher after Ruxo versus Ruxo + ECP, being 55% (95% CI: 42-69%) vs. 26% (95% CI: 22-64%) (P = 0.018). No statistically significant difference in 1-year NRM, relapse, and GRFS and survival at 3 years was observed.

Conclusion: Our data suggest improved long-term control of acute and chronic GvHD by combining Ruxo plus ECP compared with Ruxo alone.

Background: Adenomyosis and endometriosis are estrogen-driven disorders with a recognized potential for malignant transformation, particularly through atypical endometriosis. The molecular and immune mechanisms underlying this progression remain incompletely understood. However, clinical factors such as age, comorbidities, and hormonal therapy can also influence lesion behavior. The objectives were to comprehensively evaluate hormonal, proliferative-apoptotic, cell-cycle, and immune-microenvironmental alterations across the spectrum of endometrial lesions and to assess the impact of prior endometrial hyperplasia and associated clinical parameters.

Methods: Seventy-seven formalin-fixed paraffin-embedded cases were stratified into five groups: eutopic endometrium (n = 17), adenomyosis (n = 27), typical endometriosis (n = 16), atypical endometriosis (n = 10), and endometriosis-associated carcinoma (n = 24). Immunohistochemical analysis included estrogen receptor, progesterone receptor, Ki67, BCL2, P53, cyclin D1, CDK4, P16, FOXP3, CD68, and CD163. Clinical variables including age, comorbidities, and medication history were integrated into statistical analysis. Marker expression was quantified semi-quantitatively, and clinical associations with prior endometrial hyperplasia were evaluated using Kruskal-Wallis and Mann-Whitney U tests.

Results: Cyclin D1, CDK4, and P16 expression progressively increased from benign lesions to carcinoma (P < 0.001). FOXP3⁺ T cells and CD163⁺ M2 macrophages accumulated in atypical endometriosis and carcinoma, indicating an immunosuppressive microenvironment. Patients with prior atypical endometrial hyperplasia demonstrated significantly higher expression of proliferative (cyclin D1, CDK4, and P16) and immune-suppressive markers (FOXP3 and CD163) and a 66% progression to carcinoma. Clinical background factors were statistically adjusted and did not alter the overall progression trend.

Conclusion: The stepwise evolution from benign endometrial lesions to carcinoma is driven by coordinated proliferative and immune microenvironmental shifts, potentiated by a history of atypical endometrial hyperplasia. Integrating immunohistochemical and clinical risk factors may enhance early identification and surveillance of patients at high risk for endometriosis-associated carcinoma.

Background: Atrial fibrillation (AF) is a frequent but variably reported complication of thyrotoxicosis, with mechanisms that extend beyond thyroid hormone excess. Clarifying its prevalence and determinants may guide early detection and management.

Methods: We conducted a retrospective cross-sectional study of adults with thyrotoxicosis. Clinical, biochemical, and electrocardiographic data were reviewed. Associations between variables and AF were assessed using generalized linear models with robust errors, and results expressed as adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

Results: Among 801 patients with thyrotoxicosis, 65 had AF, yielding a prevalence of 8.1% (95% CI: 6.3 - 10.2). Compared with non-AF patients, those with AF were older, more often male (48% vs. 20%), and more frequently had chronic kidney disease, dyslipidemia, diabetes, heart failure (HF), cerebrovascular disease, and thyroid crisis (all P < 0.01). In multivariable analysis, independent determinants included age 35 - 60 years (adjusted OR 5.48; 95% CI: 2.03 - 14.83), age > 60 years (adjusted OR 11.39; 95% CI: 3.43 - 37.76), male sex (adjusted OR 3.38; 95% CI: 1.70 - 6.30), HF (adjusted OR 11.25; 95% CI: 2.85 - 44.54), and thyroid crisis (adjusted OR 61.84; 95% CI: 21.89 - 181.32). Thyroid hormone levels were not independently associated with AF.

Conclusion: AF was observed in approximately 8% of patients with thyrotoxicosis. The findings suggested that clinical vulnerabilities - older age, male sex, HF, and thyroid crisis - were more strongly associated with AF than thyroid hormone levels. These results supported targeted AF screening in high-risk thyrotoxic patients and indicated that rhythm management should consider patient susceptibility alongside restoring euthyroidism.

Background: Febrile patients with tachycardia present diverse profiles that complicate triage. Although the Emergency Severity Index (ESI) is widely used in Thailand, inter-rater variability limits consistency. Machine learning (ML) may enhance reliability using routinely collected triage data. The objectives were to develop and evaluate ML models predicting ESI levels 1-3 in febrile tachycardic adults and identify the best model for clinical use.

Methods: This diagnostic prediction study analyzed adults with fever (≥ 37.6 °C) and pulse rate > 100 beats per minute in the triage area of Lampang Hospital, Thailand, during June - August 2024. Patients with complete data were included, whereas referrals and expert-disagreement cases were excluded. Expert-assigned ESI levels were the outcome. Thirteen routinely collected triage variables were evaluated as candidate predictors. The dataset (n = 500) was randomly split 80:20 into development and testing sets. Random forest, extreme gradient boosting (XGBoost), and gradient boosting machine models were developed using five-fold cross-validation with class-weighting for imbalance correction. Performance was assessed using area under the receiver operating characteristic curve (AuROC), calibration, and confusion matrices, with attention to clinically relevant misclassification.

Results: XGBoost demonstrated the best discrimination with AuROC values of 1.00 (confidence interval (CI): 0.99 - 1.00), 0.94 (CI: 0.89 - 0.98), and 0.97 (CI: 0.93 - 1.00) for ESI levels 1-3 in the test set. Calibration showed the lowest Brier scores, and misclassification was minimal, supporting strong predictive consistency across categories.

Conclusions: XGBoost was selected for integration into the Smart ER system as the Thailand Triage Prediction System (TTPS), providing real-time prediction to enhance triage accuracy, support decision-making, and improve workflow.