Journal of clinical medicine research最新文献

Lipoprotein(a) (Lp(a)) is a type of lipoprotein consisting of low-density lipoprotein with apoprotein(a) (apo(a)) and is a risk factor for cardiovascular disease (CVD). Lowering Lp(a) levels may improve CVD outcomes, but this has been challenging owing to the unique structure and metabolic pathway of Lp(a). Recently, several new treatments using apo(a)-targeting drugs have been developed to reduce Lp(a) levels. Here, we briefly summarize the treatments, including earlier attempts at reducing Lp(a). Some lipid-lowering drugs can reduce Lp(a) levels in a non-targeted manner; while the effect of statins varies, niacin and proprotein convertase subtilisin/kexin type 9 inhibitors exhibit a reduction of over 20% in Lp(a) levels. Estrogen-related drugs and certain supplements can reduce Lp(a) levels, which may promote a deeper understanding of the modulation of Lp(a) levels. An apo(a) antisense oligonucleotide, small interfering RNAs, and a small molecule Lp(a)-formation inhibitor have recently been developed as promising drugs that specifically reduce Lp(a) levels by approximately 80%. The treatment strategies for Lp(a) are set to be updated, although we are awaiting clinical evidence on the reduction of CVD events by new treatments and the effective threshold for Lp(a) levels for the prevention of CVD.

Background: Assessment of center of mass (COM) changes during static stance control has practical implications in clinical settings, notably among older adults. Recently portable and wearable devices, including accelerometers and gyroscopes, have emerged as a promising alternative to traditional clinical and laboratory assessments. The objectives of the study were to evaluate COM postural sway parameters derived from accelerometer and gyroscope data during static balance tasks with varying bases of support in healthy elderly individuals, and to examine the correlation and agreement between accelerometer-based and gyroscope-based parameters in postural sway assessment.

Methods: One hundred and fourteen healthy elderly individuals who had not experienced falls within the preceding 6 months and were confirmed to have no risk of falling as determined by the timed up and go test, were included in this study. They were evaluated for postural sway while standing, using the sensor securely with a belt attached to the L5 vertebra. The four-stage balance test, including standing in a double stance (SO), semi-tandem stance (STO), tandem stance (TO), and single-leg stance (SL), was employed to assess each participant's ability to maintain balance under increasingly challenging standing positions on a stable surface.

Results: The study demonstrated that COM posture sway increased with a demanding position and a decreasing base of support. Spearman's rho correlation coefficients from the anteroposterior and mediolateral planes exhibited strong correlation (0.75 - 0.9). Moderate reliability was observed for both the accelerometer and gyroscope parameters in both planes (intraclass correlation coefficient: 0.5 and 0.75).

Conclusions: Accelerometry and gyroscopes provide objective quantification of balance that have the potential to be utilized in conjunction with clinical tests to effectively evaluate the risk of falling.

Background: Our goal in this manuscript was to perform a survival analysis and understand the causes of death (CODs) in patients with glioblastoma using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods: A retrospective cohort study was conducted using version 8.3.9.2 of SEER*Stat software to extract data from the SEER 17 Plus database. Patients with World Health Organization (WHO) grade IV glioblastoma diagnosed between 2000 and 2019 were included to calculate overall survival (OS), relative survival (RS), and conditional survival. R software was used to calculate univariate and multivariate Cox regression models for age, sex, and race to identify their effect on survival.

Results: We included 45,071 patients with grade IV glioblastoma according to WHO 2016 classification. The observed 1-year, 3-year, and 5-year survival rates showed a decline to 40.1%, 9.8%, and 5.2%, respectively. Similarly, the relative 1-year, 3-year, and 5-year survival rates were 40.7%, 10.2%, and 5.4%, respectively. The conditional 3-year survival rates improved up to 16.9%, 42.9%, and 60.2% after 1, 3, and 5 years of survival, correspondingly, with females showing better estimates. The most common cancer CODs were the brain and other central nervous system (CNS) cancers. Among non-glioblastoma cancer CODs, breast cancer was the most common cause. Additionally, cardiovascular diseases, cerebrovascular diseases, and septicemia were the most common non-cancer CODs.

Conclusion: In this study, patients with glioblastoma showed a sharp decline in OS and RS over time after diagnosis. However, there was a notable improvement in conditional 3-year survival over time. Cardiovascular diseases emerged as the most common non-cancer COD, with lower survival rates in males and advanced age.

Background: Acute interstitial pneumonia (AIP), also known as Hamman-Rich syndrome, is a rapidly progressive interstitial lung disease. In addition to being challenging to diagnose, AIP is also difficult to treat. The mortality rate of AIP is greater than 70% due to the disease's rapid progression. Furthermore, survivors are likely to develop chronic interstitial lung disease as a sequela. Treatment primarily focuses on supportive care, which consists of oxygenation through mechanical ventilation, administration of broad-spectrum antibiotics, and the use of corticosteroids. Although the use of steroids as empiric treatment is controversial and results on its mortality benefit are variable, some studies have shown high-dose pulse steroid therapy to be associated with better health outcomes. This review aimed to evaluate cases of AIP to better understand the role of corticosteroids in the management plan of these cases.

Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. Outcomes of interest included patient age, sex, autoimmune condition, corticosteroid use, survival or expiration of patients, and time from hospitalization to expiration.

Results: Initial querying of the five databases yielded 376 articles. Following a thorough review, only 30 articles remained, comprising 42 patient cases. Of these cases, 62% of the patients survived, 36% expired, and 2% were unknown. The average stay from hospitalization to death was 20.2 days, and corticosteroid pulse doses were used as a first- or second-line treatment in 31% of patients.

Conclusion: The limitations of the evidence used in this study highlight the need for a greater output of higher-level evidence in the form of controlled trials and retrospective studies to help further elucidate the proper role and dosage of corticosteroids in the management plan of AIP with the ultimate goal of enhancing clinical decision-making and patient care. The findings of this systematic review, primarily based on observational data from case reports, highlight the critical need for treatment guidelines for this condition. The compilations of these cases also illustrated the diverse strategies employed by clinicians globally to save patients afflicted by this condition. While specific recommendations cannot be made based solely on these results, we anticipate that this comprehensive overview of varied clinical approaches from around the world will serve as a valuable resource for healthcare providers navigating the complexities of managing this condition.

Background: Reports on the comparative mortality among mechanically ventilated patients with coronavirus disease 2019 (COVID-19) and influenza show conflicting findings, but studies focused largely on the early phase of the pandemic, using historical influenza comparators. We sought to examine the population-level comparative mortality among mechanically ventilated patients with COVID-19 during the latter pandemic years using contemporaneous influenza comparators.

Methods: We used a statewide dataset to identify mechanically ventilated hospitalizations aged ≥ 18 years with COVID-19 or influenza in Texas between October 2021 and March 2023. Their comparative short-term mortality (in-hospital death or discharge to hospice) was estimated using overlap propensity score weighting (primary model), entropy balance, and hierarchical logistic models.

Results: Among 22,195 mechanically ventilated hospitalizations, 19,659 (88.6%) had COVID-19 and 2,536 (11.4%) had influenza. Compared to mechanically ventilated hospitalizations with influenza, those with COVID-19 were more commonly racial or ethnic minority (49.3% vs. 48.4%) and had lower mean (standard deviation (SD)) Deyo comorbidity index (2.04 (2.03) vs. 2.53 (1.91)), but higher number of organ dysfunctions (2.60 (1.37) vs. 2.13 (1.27)), respectively. Short-term mortality among mechanically ventilated hospitalizations with COVID-19 and influenza was 49.1% vs. 20.7%. The risk of short-term mortality was attenuated but remained higher among hospitalizations with COVID-19 in the primary model (adjusted risk ratio: 1.24 (95% confidence interval (CI): 1.18 - 1.30); adjusted risk difference 8.8% (95% CI: 6.7 - 10.4)), with consistent findings in alternative models, subgroups, and sensitivity analyses.

Conclusions: Population-level short-term mortality among mechanically ventilated hospitalizations with COVID-19 has been higher than that among those with influenza during the latter years of the pandemic.

Background: β-Thalassemia is a genetic disorder characterized by decreased or completely absent β-globin synthesis, leading to a spectrum of clinical manifestations. It is a major public health concern in Jordan, as in other Mediterranean countries. β-Thalassemia carriers are normally asymptomatic; nevertheless, laboratory examinations often reveal mild anemia characterized by microcytic hypochromic erythrocytes, with differences influenced by specific phenotypes. This study aimed to assess and correlate the variants among β⁰ and β⁺ phenotypes in the Jordanian population with hematological characteristics, as well as establish and determine reference values for distinguishing between the two phenotypes.

Methods: One hundred forty-five β-thalassemia carriers were recruited from various governorates in Jordan. Hematological parameters, including complete blood count (CBC) and capillary electrophoresis of hemoglobin (Hb), were evaluated in all participants. Molecular techniques, specifically polymerase chain reaction (PCR) with hybridization, were employed to identify β-thalassemia variants and classify the participants as having β⁰ and β⁺ phenotypes.

Results: Among the 145 β-thalassemia carriers, 64 (44.14%) and 81 (55.86%) had β⁰-thalassemia and β⁺-thalassemia, respectively. Participants exhibiting a cutoff value of Hb (≤ 11.0 g/dL), mean corpuscular volume (MCV) (≤ 64.0 fL), mean corpuscular hemoglobin (MCH) (≤ 19.0 pg), and hemoglobin A₂ (Hb-A₂) (≥ 5.00%) were classified as having the β⁰ phenotype. These participants demonstrated significantly lower mean Hb, MCV, MCH, and higher mean Hb-A₂ than the participants with the β⁺ phenotype (P < 0.0001).

Conclusions: Hb, MCV, MCH, and Hb-A₂ can serve as effective screening tools for predicting β⁰- and β⁺-thalassemia in the Jordanian population. These findings have important clinical implications for early diagnosis, genetic counseling, and prenatal screening of β-thalassemia.

Case 1 involved a 34-year-old woman who had been diagnosed with Crohn's disease (CD) at 30 years old. After deciding to discontinue CD treatment, she was diagnosed with moderate flare-up of CD based on disease activity and endoscopic findings. Inadequate response was seen 7 days after starting oral prednisolone (PSL) at 30 mg/day, so combination therapy was started with intensive granulocyte and monocyte adsorptive apheresis (GMA) plus upadacitinib (UPA) at 45 mg/day. Twelve weeks after starting this combination therapy, clinical remission and endoscopic and histological improvements of the inflamed mucosa were achieved with no adverse events. Case 2 involved a 26-year-old man who had been diagnosed with CD at 13 years old. He was diagnosed with severe flare-up of CD based on disease activity and endoscopic findings due to loss of response to double doses of infliximab (IFX). Combination therapy was started with intensive GMA plus UPA at 45 mg/day. Twelve weeks after starting this therapy, clinical remission and endoscopic and histological improvements of the inflamed mucosa were achieved with no adverse events. The combination of intensive GMA plus UPA appears to have provided an effective therapeutic option for refractory CD in a patient with a 4-year history of CD and refractoriness to systemic corticosteroids, and in another patient with a 13-year history of CD and loss of response to IFX.

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.