Hasil untuk "Specialties of internal medicine"

Daniel Becker, MD, Ahmed Ali, MD, Anja Lehmann, MD et al.

Objective: Juxtarenal abdominal aortic aneurysms (AAAs), pose a greater surgical challenge than infrarenal AAAs and often require suprarenal aortic clamping during open repair. This study aims to assess the impact of suprarenal vs infrarenal clamping on short- and long-term renal outcomes, mortality, and reintervention rates. Methods: A retrospective cohort analysis was conducted on 1250 patients undergoing open AAA repair between 2000 and 2020 at a tertiary vascular center. Patients were stratified into suprarenal and infrarenal clamping groups. Outcomes included 30-day mortality, major adverse events, acute kidney injury, new-onset dialysis, chronic kidney disease (CKD), long-term mortality, and reintervention. Propensity score matching and multivariate analysis were used to adjust for confounders. Results: Of the cohort, 492 underwent suprarenal and 758 infrarenal clamping. The suprarenal group experienced higher 30-day major adverse events (20.9% vs 16.2%; P = .036), acute kidney injury (37.6% vs 22.0%; P < .001), and new-onset dialysis (4.5% vs 1.8%; P = .009). At a median follow-up of 8.6 years, CKD incidence was significantly higher in the suprarenal group (28.5% vs 21.1%; P = .004), as was all-cause mortality (41.3% vs 32.4%; P < .001). We found no difference in reintervention rates between groups. In the propensity-matched cohort, CKD remained significantly more common with suprarenal clamping (P < .001), whereas differences in mortality were not statistically significant. Conclusions: Suprarenal clamping during open AAA repair is associated with increased postoperative renal complications and long-term CKD and mortality, despite similar reintervention and short-term mortality rates. These findings support the need for individualized surgical planning.

Stanley E. Lazic

Reproducibility is central to the credibility of scientific findings, yet complete replication studies are costly and infrequent. However, many biological experiments contain internal replication, which is defined as repetition across batches, runs, days, litters, or sites that can be used to estimate reproducibility without requiring additional experiments. This internal replication is analogous to internal validation in prediction or machine learning models, but is often treated as a nuisance and removed by normalisation, missing an opportunity to assess the stability of results. Here, six types of internal replication are defined based on independence and timing. Using mice data from an experiment conducted at three independent sites, we demonstrate how to quantify and test for internal reproducibility. This approach provides a framework for quantifying reproducibility from existing data and reporting more robust statistical inferences in preclinical research.

Erik Horsdal

The forces that act internally in a trebuchet as it delivers a shot depend on the motions of throwing arm, counterweight and sling. These motions are considered known experimentally or theoretically and given in the form of time-dependent angular coordinates. Explicit expressions in terms of these coordinates and their derivatives to second order are derived for the internal forces. The forces that act immediately after a shot is initiated can be extracted from the equations of motion without solving them, and they are compared with static forces just prior to initiation. Required strengths of the different parts of a trebuchet depend on the internal forces, which also determine sliding friction losses. Illustrative results are given for a specific trebuchet.

Kathryn M Ross, L. Lynn, K. Foley et al.

Only 62.6% of fellowship‐trained and American Board of Internal Medicine (ABIM)‐certified geriatricians maintain their specialty certification in geriatric medicine, the lowest rate among all internal medicine subspecialties and the only subspecialty in which physicians maintain their internal medicine certification at higher rates than their specialty certification. This study aims to better understand underlying issues related to the low rate of maintaining geriatric medicine certification in order to inform geriatric workforce development strategies.

GAF Maia, JLR Cunha-Júnior, A Erbetta et al.

Introdução: A infecção por Dengue é transmitida pelo mosquito Aedes aegypti e constitui um grande problema de saúde pública, principalmente em regiões tropicais, onde o meio ambiente favorece sua proliferação e apresenta significativa morbidade. As epidemias de Dengue têm apresentado um problema recorrente no setor de saúde pública, caracterizado por surtos intermitentes de casos e uma extensão das regiões afetadas. As manifestações da Dengue são muito complexas, com quadro febril e de evolução benigna na sua forma clássica, mas agressiva na sua forma grave, sendo uma das mais importantes arboviroses que afeta o homem. Os achados laboratoriais no hemograma são importantes para a caracterização fisiopatológica da gravidade, através de valores crescentes do hematócrito com a hemoconcentração e diminuição das plaquetas nas manifestações hemorrágicas. Na Dengue Clássica, a leucopenia é achado usual (embora possa ocorrer leucocitose), pode estar presente linfocitose com reatividade linfocitária e a trombocitopenia é observada ocasionalmente. Na Dengue Grave a contagem de leucócitos é variável, podendo ocorrer desde a leucopenia até a leucocitose leve, e a linfocitose com reatividade linfocitária é um achado comum. Destacam-se a concentração de hematócrito e a trombocitopenia, com contagem de plaquetas abaixo de 100.000/mm3. Objetivos: Analisar o perfil de hemogramas realizados no período de 12/01/2024 a 26/02/2024 de casos positivos para Dengue. Métodos: Este estudo contou com amostras de sangue positivas para Dengue, coletadas no período de 12/01/2024 a 26/02/2024, enviadas para análise de rotina com o pedido de hemograma para o Laboratório de Hematologia do Hospital de Clínicas da UNICAMP (Campinas-SP). As amostras (n = 59) foram incluídas no estudo, independentemente da idade, que variou de 20 anos a 75 anos. As amostras foram processadas no analisador automatizado (Sysmex XN-9000). Para todas as amostras de sangue foram confeccionados os esfregaços, os quais foram avaliados por microscopia pelos profissionais do laboratório. As análises estatísticas utilizadas foram descritiva e correlação de Pearson. Resultados/Discussão: Das amostras analisadas, 39% (23) foram do sexo feminino e 61% (36) do sexo masculino. 1,69% (1 amostra) apresentou contagem de leucócitos acima de 10 × 103/mm3, 37,3% (22 amostras) apresentaram leucócitos abaixo de 4 × 103/mm3 e 61% (36 amostras) estavam dentro dos valores de referência. Plaquetopenia foi observada em 10,2% das amostras (6 amostras), que cursaram com presença expressiva de linfócitos reativos. Não houve correlação entre o número total de leucócitos e o número de plaquetas com um r = -0.0408. Quando comparamos número de plaquetas e presença de linfócitos reativos obtivemos uma correlação moderada negativa de r = -0.5008. 66,7% das amostras (4 amostras) com plaquetopenia também cursaram com leucopenia. Entre as amostras analisadas, 89,83% (53 amostras) apresentaram plaquetas acima de 100 x 103/mm3, sendo 33,97% (18 amostras) com leucopenia. Conclusão: O perfil dos resultados obtidos no Hemograma em pacientes positivos para Dengue são compatíveis com a dados da literatura. O agravamento desta arbovirose apresentou ao hemograma resultados de plaquetopenia, presença de linfócitos reativos e em alguns casos a leucopenia. Na Dengue clássica também obtivemos dados que corroboram com achados da literatura.

Kanehiro Hiyama, MD, PhD, Takuya Takakuwa, MD, Reiko Yamaguchi, MD et al.

S. Navarro-Obregón, J. Queiruga

We study the sphaleron solutions in two deformations of the $φ^6$ model and analyze the oscillons originated from them. We find that the presence of internal modes plays a crucial role in the sphaleron collapse. The positive internal modes triggered by a squeezing of the sphaleron are able to change the direction of collapse. We provide an analytical understanding behind this phenomenon.

Noam Schiller, Hiromi Ebisu, Gil Refael et al.

We demonstrate that the effective internal entropy of quasiparticles within the non-Abelian fractional quantum Hall effect manifests in the heat current through a tunneling barrier. We derive the electric current and heat current resulting from voltage and heat biases of the junction, taking into account the quasiparticles' internal entropy. We find that when the tunneling processes are dominated by quasiparticle tunneling of one type of charge, the effective internal entropy can be inferred from the measurement of the heat current and the charge current. Our methods may be used to conclusively identify non-Abelian quasiparticles, such as the anyons that emerge in the $ν= 5/2$ fractional quantum Hall state.

Xiaoye Wang, Nicole Xi Zhang, Hongyu He et al.

Recent advancements in artificial intelligence (AI), particularly in large language models (LLMs), have unlocked significant potential to enhance the quality and efficiency of medical care. By introducing a novel way to interact with AI and data through natural language, LLMs offer new opportunities for medical practitioners, patients, and researchers. However, as AI and LLMs become more powerful and especially achieve superhuman performance in some medical tasks, public concerns over their safety have intensified. These concerns about AI safety have emerged as the most significant obstacles to the adoption of AI in medicine. In response, this review examines emerging risks in AI utilization during the LLM era. First, we explore LLM-specific safety challenges from functional and communication perspectives, addressing issues across data collection, model training, and real-world application. We then consider inherent safety problems shared by all AI systems, along with additional complications introduced by LLMs. Last, we discussed how safety issues of using AI in clinical practice and healthcare system operation would undermine trust among patient, clinicians and the public, and how to build confidence in these systems. By emphasizing the development of safe AI, we believe these technologies can be more rapidly and reliably integrated into everyday medical practice to benefit both patients and clinicians.

Minda Hu, Qiyuan Zhang, Yufei Wang et al.

As a crucial step to enhance LLMs alignment with human intentions, Instruction Fine-Tuning (IFT) has a high demand on dataset quality. However, existing IFT datasets often contain knowledge that is inconsistent with LLMs' internal knowledge learned from the pre-training phase, which can greatly affect the efficacy of IFT. To address this issue, we introduce NILE (iNternal consIstency aLignmEnt) framework, aimed at optimizing IFT datasets to unlock LLMs' capability further. NILE operates by eliciting target pre-trained LLM's internal knowledge corresponding to instruction data. The internal knowledge is leveraged to revise the answer in IFT datasets. Additionally, we propose a novel Internal Consistency Filtering (ICF) method to filter training samples, ensuring its high consistency with LLM's internal knowledge. Our experiments demonstrate that NILE-aligned IFT datasets sharply boost LLM performance across multiple LLM ability evaluation datasets, achieving up to 66.6% gain on Arena-Hard and 68.5% on Alpaca-Eval V2. Further analysis confirms that each component of the NILE}framework contributes to these substantial performance improvements, and provides compelling evidence that dataset consistency with pre-trained internal knowledge is pivotal for maximizing LLM potential.

Bernardo A Pons-Estel

Clément Klein, Thibault Marquette, Grégoire Capon et al.

ObjectiveHolmium laser enucleation of the prostate (HoLEP) has been recommended for the surgical management of benign prostatic hyperplasia (BPH) in most of the international guidelines, regardless of prostatic volume. The main advantages reported by randomized clinical studies are reduced perioperative bleeding, catheterization time, and length of hospital stay, but this technique is also described as difficult to master with a steep learning curve. The objective of this study was to describe the clinical outcomes of HoLEP in the real-life setting of an academic department with multiple operators with no previous experience.MethodsA retrospective observational study was conducted including all consecutive cases performed in our department from April 2012 to October 2020. Over the study period, 31 different operators were involved. In April 2012, 2 surgeons were trained by an experienced urologist. The 29 others learned the technique progressively with the help of the first 2 surgeons (surgical mentoring).ResultsA total of 1259 patients were included. Preoperatively, the mean prostate volume and Qmax were 82.3 g and 9.4 mL/s, respectively. The mean operative time was 79.7 min. The intraoperative complication rate was 5.6% (n = 71), with the need for conversion being 0.6%. Postoperatively, the complication rate was 18.6% (n = 234). Surgeon’s experience reduced the perioperative complication rates (P = 0.01), operative time (P < 0.001), and length of hospital stay (P < 0.001), but the difference in blood transfusion rate was statistically non-significant (P = 0.3).ConclusionsMost of the 31 urologists in training were able to master HoLEP progressively, with good functional outcomes and acceptable complication rates. Supervision by trained urologists was critical for the safe dissemination of the technique in our department.

Liu Miao, Yan-Li Liu

Cardiovascular disease is one of the major diseases threatening the health of Chinese residents, and the death rate has long been the highest on the disease spectrum in China. With the progress of population aging, the prevalence and mortality of cardiovascular diseases remain on the rise, and the current treatment effect on and prognosis of heart failure (HF) are not satisfactory. It is particularly important to explore the potential pathogenic mechanisms of HF and identify new therapeutic targets.

Peng Gao, Yu Jin, Peiyao Zhang et al.

BackgroundAcute kidney injury (AKI) is common after cardiac surgery with cardiopulmonary bypass (CPB) and is associated with increased mortality and morbidity. Nadir indexed oxygen delivery (DO2i) lower than the critical threshold during CPB is a risk factor for postoperative AKI. The critical DO2i for preventing AKI in children has not been well studied. The study aimed to explore the association between nadir DO2i and postoperative AKI in infant cardiac surgery with CPB.MethodsFrom August 2021 to July 2022, 413 low-weight infants (≤10 kg) undergoing cardiac surgery with CPB were consecutively enrolled in this prospective observational study. Nadir DO2i was calculated during the hypothermia and rewarming phases of CPB, respectively. The association between nadir DO2i and postoperative AKI was investigated in mild hypothermia (32–34°C) and moderate hypothermia (26–32°C).ResultsA total of 142 (38.3%) patients developed postoperative AKI. In patients undergoing mild hypothermia during CPB, nadir DO2i in hypothermia and rewarming phases was independently associated with postoperative AKI. The cutoff values of nadir DO2i during hypothermia and rewarming phases were 258 mL/min/m2 and 281 mL/min/m2, respectively. There was no significant association between nadir DO2i and postoperative AKI in patients undergoing moderate hypothermia during CPB.ConclusionIn low-weight infants undergoing mild hypothermia during CPB, the critical DO2i for preventing AKI was 258 mL/min/m2 in the hypothermia phase and 281 mL/min/m2 for rewarming. Moreover, an individualized critical DO2i threshold should be advocated during CPB.

Stéphane Cook, Diego Arroyo

Yu. A. Lutokhina, O. V. Blagova, A. V. Nedostup et al.

Aim. To assess the contribution of genetic and inflammatory factors to the development of arrhythmogenic right ventricular cardiomyopathy (ARVC).Material and methods. The study involved 54 patients with ARVC (age, 38,7±14,1 years; men, 42,6%; mean follow-up period, 21 [6; 60] months). All patients underwent electrocardiography (ECG), 24-hour ECG monitoring, echocardiography, determination of anticardiac antibodies and DNA of cardiotropic viruses in the blood, molecular genetic ARVC testing, as well as cardiac magnetic resonance imaging (n=49), high-resolution ECG (n=18), right ventricular endomyocardial biopsy (n=2), and autopsy (n=2).Results. Following four clinical types of ARVC were identified: I. Latent arrhythmic form: characterized by frequent premature ventricular contractions and/or nonsustained ventricular tachycardia (VT). II. Manifested arrhythmic form (n=11) — SVT/ventricular fibrillation (VF). III. ARVC with progressive heart failure (HF, n=8). IV. Combination of ARVC with left ventricular noncompaction (LVNC, n=8). Superimposed myocarditis was identified in 74%, 36%, 87,5% and 85,7% of patients in forms I-IV, respectively. Mutations were detected in 11%, 46%, 50%, and 38% of patients in forms I-IV, respectively. Clinical forms were stable: there was no transition from one clinical form to another during follow-up period.Conclusion. The contribution of genetic and inflammatory mechanisms to the clinical picture is different: in the latent arrhythmic form, the leading role belongs to inflammation; in the manifested arrhythmic form, the contribution of pathogenic mutations prevails, and in ARVC with progressive HF and in combination with LVNC, the contribution of genetic and inflammatory factors is equally important.

Wenqun Xing, Lingdi Zhao, Yan Zheng et al.

BackgroundThere is no standard neoadjuvant therapy for locally advanced esophageal cancer in China. The role of neoadjuvant chemotherapy plus immunotherapy for locally advanced esophageal cancer is still being explored.MethodsThis open-label, randomized phase II study was conducted at a single center between July 2019 and September 2020; 30 patients with locally advanced esophageal squamous cell carcinoma (ESCC) (T3, T4, or lymph-node positive) were enrolled. Patients were randomized according to the enrollment order at a 1:1 ratio to receive chemotherapy on day 1 and toripalimab on day 3 (experimental group) or chemotherapy and toripalimab on day 1 (control group). The chemotherapeutic regimen was paclitaxel and cisplatin. Surgery was performed 4 to 6 weeks after the second cycle of chemoimmunotherapy. The primary endpoint was pathological complete response (pCR) rate, and the secondary endpoint was safety and disease-free survival.ResultsThirty patients completed at least one cycle of chemoimmunotherapy; 11 in the experimental group and 13 in the control group received surgery. R0 resection was performed in all these 24 patients. Four patients (36%) in the experimental group and one (7%) in the control group achieved pCR. The experimental group showed a statistically non-significant higher pCR rate (p = 0.079). PD-L1 combined positive score (CPS) examination was performed in 14 patients; one in the control group had a PD-L1 CPS of 10, and pCR was achieved; the remaining 13 all had ≤1, and 11 of the 13 patients received surgery in which two (in the experimental group) achieved pCR. Two patients endured ≥grade 3 adverse events, and one suffered from grade 3 immune-related enteritis after one cycle of chemoimmunotherapy and dropped off the study. Another patient died from severe pulmonary infection and troponin elevation after surgery.ConclusionsAlthough the primary endpoint was not met, the initial results of this study showed that delaying toripalimab to day 3 in chemoimmunotherapy might achieve a higher pCR rate than that on the same day, and further large-sample clinical trials are needed to verify this.Clinical Trial RegistrationClinicalTrials.gov, identifier NCT 03985670.

Hyo Jin Yun, Soo Ryeong Ryoo, Jung-Eun Kim et al.

Abstract Background In the general population, the trabecular bone score (TBS) represents the bone microarchitecture and predicts fracture risk independent of bone mineral density (BMD). A few studies reported that TBS is significantly reduced in dialysis patients. Chronic kidney disease-mineral and bone disorder (CKD-MBD) are accompanied by increased fracture risk, cardiovascular morbidity, and mortality. We investigated whether TBS is associated with comorbidity related to CKD-MBD or frailty in hemodialysis patients. Methods In this prospective observational study, TBS was obtained using the TBS iNsight software program (Med-Imaps) with BMD dual energy x-ray absorptiometry (DXA) images (L1–L4) from prevalent hemodialysis patients. A Tilburg frailty indicator was used to evaluate frailty, and hand grip strength and bio-impedance (InBody) were measured. A patient-generated subjective global assessment (PG-SGA) was used for nutritional assessment. The history of cardiovascular events (CVE) and demographic, clinical, laboratory, and biomarker data were collated. We then followed up patients for the occurrence of CKD-MBD related complications. Results We enrolled 57 patients in total. The mean age was 56.8 ± 15.9 years (50.9% female). Prevalence of Diabetes mellitus (DM) was 40.4% and CVE was 36.8%. Mean TBS was 1.44 ± 0.10. TBS significantly reduced in the CVE group (1.38 ± 0.08 vs. 1.48 ± 0.10, p <  0.001). Multivariable regression analysis was conducted adjusting for age, sex, dialysis vintage, DM, CVE, albumin, intact parathyroid hormone, fibroblast growth factor 23, handgrip strength, and phosphate binder dose. Age (ß = − 0.030; p = 0.001) and CVE (ß = − 0.055; p = 0.024) were significant predictors of TBS. During the follow up period after TBS measurements (about 20 months), four deaths, seven incident fractures, and six new onset CVE were recorded. Lower TBS was associated with mortality (p = 0.049) or new onset fracture (p = 0.007, by log-rank test). Conclusion Lower TBS was independently associated with increased age and CVE prevalence in hemodialysis patients. Mortality and fracture incidence were significantly higher in patients with lower TBS values. These findings suggest that TBS may indicate a phenotype of frailty and also a CKD-MBD phenotype reciprocal to CVE.

Manabu Nagayama, Tomonori Yano, Koji Atarashi et al.

Dysbiotic microbiota contributes to the pathogenesis of Crohn’s disease (CD) by regulating the immune system. Although pro-inflammatory microbes are probably enriched in the small intestinal (SI) mucosa, most studies have focused on fecal microbiota. This study aimed to examine jejunal and ileal mucosal specimens from patients with CD via double-balloon enteroscopy. Comparative microbiome analysis revealed that the microbiota composition of CD SI mucosa differs from that of non-CD controls, with an increased population of several families, including Enterobacteriaceae, Ruminococcaceae, and Bacteroidaceae. Upon anaerobic culturing of the CD SI mucosa, 80 bacterial strains were isolated, from which 9 strains representing 9 distinct species (Escherichia coli, Ruminococcus gnavus, Klebsiella pneumoniae, Erysipelatoclostridium ramosum, Bacteroides dorei, B. fragilis, B. uniformis, Parabacteroides distasonis, and Streptococcus pasteurianus) were selected on the basis of their significant association with CD. The colonization of germ-free (GF) mice with the 9 strains enhanced the accumulation of TH1 cells and, to a lesser extent, TH17 cells in the intestine, among which an E. coli strain displayed high potential to induce TH1 cells and intestinal inflammation in a strain-specific manner. The present results indicate that the CD SI mucosa harbors unique pro-inflammatory microbiota, including TH1 cell-inducing E. coli, which could be a potential therapeutic target.

Géraldine Davis, Timothée Jamin, Julie Deleuze et al.

We study experimentally the interaction of nonlinear internal waves in a stratified fluid confined in a trapezoidal tank. The set-up has been designed to produce internal wave turbulence from monochromatic and polychromatic forcing through three processes. The first is a linear transfer in wavelength obtained by wave reflection on inclined slopes, leading to an internal wave attractor which has a broad wavenumber spectrum. Second is the broad banded time-frequency spectrum of the trapezoidal geometry, as shown by the impulse response of the system. The third one is a nonlinear transfer in frequencies and wavevectors via triadic interactions, which results at large forcing amplitudes in a power law decay of the wavenumber power spectrum. This first experimental spectrum of internal wave turbulence displays a $k^{-3}$ behavior.