Hasil untuk "Specialties of internal medicine"

J. Rex, M. G. Rinaldi, M. Pfaller

Kei Ito, Akira Endo, Hiromasa Hoshi et al.

ABSTRACT Background Although surgical treatment is the primary measure for patients with perforated peptic ulcer (PPU), nonoperative management (NOM) has become a common alternative. However, risk score models predicting the success of NOM based on the analysis of a large number of patients remain scarce. We developed a clinically applicable scoring system to predict the success of NOM in patients with PPU using data from a large cohort. Method We analyzed data of the Perforated Peptic ulcer Analyzing Project (PPAP), which was a retrospective survey of adult patients with PPU between January 2011 to December 2022. The successful NOM case was defined as patients who survived until hospital discharge without requiring surgery. Factors associated with NOM were identified using a multivariable logistic regression analysis, and a scoring system to predict NOM was developed by weighting these factors based on the regression coefficients. Result Of 702 potentially eligible patients, 584 were treated with NOM, of which 130 patients (22.2%) were treated successfully. Age, sex, body temperature, heart rate, the extent of peritoneal irritation signs, C reactive protein, spread of ascites, and sepsis were included in the final model. Using these variables, we developed the scoring system named PPAP score, which had favorable discriminating ability with the area under receiving operating characteristic curve of 0.799. When the cut‐off was set to 56, the sensitivity and the specificity were 0.738 and 0.722, respectively. Conclusion A predictive scoring model was developed. However, external validation of the model is required to confirm its clinical applicability.

C. Baracchini, A. Pieroni, F. Viaro et al.

Since the outbreak of the COVID-19 epidemic which in our region, Veneto (Italy), dates back to February, we were confronted with several challenges, but with a constant aim of keeping our Stroke Unit COVID-free. For this reason, in addition to creating a dedicated hot-spot as a pre-triage just outside the Emergency Department, together with the Neuroradiology Unit we obtained a mobile CT unit that could be used by COVID-positive or COVID-suspected patients. Furthermore, thanks to the collaboration with colleagues from different specialties (Infectious Disease, Internal Medicine, Intensive Care, Emergency Medicine), dedicated areas for COVID patients were activated. This led to a substantial change of our acute stoke management pathway. As the number of COVID patients increased, and the WHO declared a state of pandemic, this new stroke pathway has been fully tested. We would like to share our experience and send a clear message to keep a high attention on stroke as an emergency condition, because we have observed a decreased number of patients with minor strokes and TIAs, longer onset-to-door and door-to-treatment times for major strokes, and a reduced number of transfers from spokes. We strongly believe that the general population and family doctors are rightly focused on COVID. However, to remain at home with stroke symptoms does not mean to “stay safe at home”.

Alexandre D´Agostini Zottis, Júlia Luiz Agostinho, Eduardo Ricardo Santana et al.

Resumo: Introdução/Justificativa: O câncer engloba mais de 100 tipos de doenças malignas caracterizadas pelo crescimento descontrolado de células, que podem invadir tecidos adjacentes ou se espalhar para outras partes do corpo. Há décadas, as nanopartículas magnéticas (NPMs) de óxido de ferro vêm sendo estudadas por apresentarem grande potencial para aplicações biomédicas, especialmente na oncologia, no uso de agentes de contraste para imagem por ressonância magnética no realçamento de contraste negativo nos tecidos com a presença de tumores e não tumorais, em magneto hipertermia para destruição seletiva de células cancerosas e atuando no transporte vetorizado de fármacos quimioterápicos. Independente de suas aplicações biomédicas, para evitar a aglomeração das NPMs em células, tecidos e órgãos, que pode levar a embolismos, é essencial recobri-las com materiais biocompatíveis e não citotóxicos. Poliésteres derivados de lactonas e macrolactonas, como o copoliéster poli(globalide-co-ε-caprolactona) (PGlCL), têm sido explorados devido à sua biocompatibilidade, hidrofilicidade e biodegradabilidade. Objetivos: Este trabalho teve como objetivo a modificação e a funcionalização do copoliéster PGICL com cisteína, a fim de atingir três objetivos associados a funcionalização das NPMs, que garantirão sua aplicação em nanomedicina, tais como: a) melhorar sua hidrofilicidade (diminuindo sua cristalinidade) para que seja carreado com mais facilidade no meio intracelular; b) permitir que grupos amina e tiol sejam pontos de ancoragem para constituírem partes de ligantes com receptores de superfície celular, tais como o ácido fólico (AF) que só são expressos em células tumorais e c) possibilitar a ligação desses grupos químicos em sistemas de ''drug-delivery'' com o análogo do AF, o quimioterápico metotrexato (MTX) para o tratamento de câncer de mama. Neste estudo, o PGlCL foi modificado com cisteína (PGlCL-Cys) e utilizado para recobrir NPMs de óxido de ferro (Fe3O4 - magnetita), visando futuramente em um segundo passo, a funcionalização com AF e MTX em aplicações como vetorização ativas em sistemas como “drug-delivery” e a posteriori, em ensaios in vitro de radiosensibilização em células de câncer de mama. Materiais e Métodos: Soluções de Fe³⁺ e Fe²⁺ em HCl. Sob refluxo, adicionaram-se H₂O aquecida, NH₄OH (30mL, pH10, 90°C), PGICL em etanol. Agitou-se 45min, purificou-se com imã, lavou-se e armazenou as NPMs. Resultados: A caracterização físico-química das NPMs recobertas com PGlCL-Cys foi realizada por espectroscopia no infravermelho, confirmando a presença de bandas características da cisteína (ligações C-S-C em 715,21 cm⁻¹ e C-N em 1573,1 cm⁻¹) e do recobrimento das NPMs (bandas de deformação angular da ligação Fe- O em 635,63 cm⁻¹ e ∼590 cm⁻¹, correspondentes aos sítios octaédricos e tetraédricos da magnetita, respectivamente). A Microscopia Eletrônica de Transmissão (MET) revelou que as NPMs de Fe3O4@PGlCL-Cys possuem um diâmetro médio de 11,44 nm e exibem comportamento superparamagnético. Conclusão: Conclui-se que o método de coprecipitação e a síntese do copoliéster modificado com cisteína (PGlCL-Cys) foi eficaz, produzindo NPMs estáveis e monodispersas de modo que serão realizados futuramente outras caracterizações físico-químcias para avançar os estudos em ensaios biológicos in vitro para citotoxicidade e biocompatibilidade a fim de serem aplicadas no diagnóstico e tratamento de câncer de mama.

Suvijak Untaaveesup, MD, Thipsukon Amnartpanich, MD, Noraworn Jirattikanwong, MD et al.

Background: Chronic systemic inflammation in individuals with moderate-to-severe atopic dermatitis (AD) potentially predisposes them to metabolic and cardiovascular diseases. Nevertheless, evidence with regard to such association is limited. Objective: To assess the association between metabolic and cardiovascular outcomes and moderate-to-severe AD. Methods: A systematic search was performed through PubMed, Scopus, EMBASE, and Cochrane for population-based studies that addressed the effects of moderate-to-severe AD on metabolic and cardiovascular outcomes compared with the general population from inception to August 31, 2023. Meta-analysis was performed using the random effects model. The pooled odds ratio (OR) and certainty of evidence for each outcome were reported. Results: We included 11 studies, 4 retrospective cohorts, 1 prospective cohort, 4 cross-sectional, and 2 case-control studies involving 405,170 moderate-to-severe AD patients compared to 4,591,478 unaffected controls. Moderate-to-severe AD was associated with a higher risk of myocardial infarction with an OR (95% CI) of 1.33 (1.07, 1.65), angina 1.33 (1.06, 1.66), heart failure 1.56 (1.28, 1.90), stroke 1.45 (1.21, 1.74), hypertension 1.38 (1.18, 1.63), dyslipidemia 1.27 (1.15, 1.41), and metabolic syndrome 1.24 (1.05, 1.42) with very low certainty of evidence. No significantly increased risk of cardiovascular death with an odds ratio (95% CI) of 1.81 (0.96, 3.44) and diabetes of 1.24 (0.91, 1.68) was observed. High heterogeneity was observed in most studies for all of the outcomes. Conclusion: Our meta-analysis demonstrated a modest but significant association between moderate-to-severe AD and increased susceptibility to metabolic and cardiovascular diseases. Initial assessment of cardiovascular and metabolic risk for patients with moderate-to-severe AD should be considered to enable early management strategies.

Nicole DeMarco, Shannon Carpenter, Brian Lee

Zhen Wang, Honglei Guo, Yanqi Song et al.

Lung cancer is the most common malignant tumor in the world. Presently, there are still problems, including a high recurrence rate, resistance, and serious toxic side effects, even if conventional treatments like chemotherapy, radiotherapy, and targeted therapy have somewhat improved patient survival. Even though immune checkpoint inhibitors that target programmed cell death-1/programmed cell death ligand 1 have fundamentally altered the therapeutic paradigm, the core mechanism is strongly linked to tumor immune escape, and some patients continue to have poor response rates or treatment resistance. The mechanisms of immune escape in the immunological microenvironment of lung cancer, involving metabolic reprogramming, overexpression of immune checkpoint molecules, and abnormalities in antigen presentation, are systematically summarized in this review. The article also sums up new therapeutic targets and promising clinical trials. The goal is to provide a solid theoretical foundation for further research into the immune escape mechanism, the creation of new immunotherapeutic targets, and personalized therapeutic strategies.

Pinar Bisgin, Tom Strube, Niklas Tschorn et al.

Noisy labels pose significant challenges for AI model training in veterinary medicine. This study examines expert assessment ambiguity in canine auscultation data, highlights the negative impact of label noise on classification performance, and introduces methods for label noise reduction. To evaluate whether label noise can be minimized by incorporating multiple expert opinions, a dataset of 140 heart sound recordings (HSR) was annotated regarding the intensity of holosystolic heart murmurs caused by Myxomatous Mitral Valve Disease (MMVD). The expert opinions facilitated the selection of 70 high-quality HSR, resulting in a noise-reduced dataset. By leveraging individual heart cycles, the training data was expanded and classification robustness was enhanced. The investigation encompassed training and evaluating three classification algorithms: AdaBoost, XGBoost, and Random Forest. While AdaBoost and Random Forest exhibited reasonable performances, XGBoost demonstrated notable improvements in classification accuracy. All algorithms showed significant improvements in classification accuracy due to the applied label noise reduction, most notably XGBoost. Specifically, for the detection of mild heart murmurs, sensitivity increased from 37.71% to 90.98% and specificity from 76.70% to 93.69%. For the moderate category, sensitivity rose from 30.23% to 55.81% and specificity from 64.56% to 97.19%. In the loud/thrilling category, sensitivity and specificity increased from 58.28% to 95.09% and from 84.84% to 89.69%, respectively. These results highlight the importance of minimizing label noise to improve classification algorithms for the detection of canine heart murmurs. Index Terms: AI diagnosis, canine heart disease, heart sound classification, label noise reduction, machine learning, XGBoost, veterinary cardiology, MMVD.

Yuhan Tang

Type 2 diabetes prevention and treatment can benefit from personalized lifestyle prescriptions. However, the delivery of personalized lifestyle medicine prescriptions is limited by the shortage of trained professionals and the variability in physicians' expertise. We propose an offline contextual bandit approach that learns individualized lifestyle prescriptions from the aggregated NHANES profiles of 119,555 participants by minimizing the Magni glucose risk-reward function. The model encodes patient status and generates lifestyle medicine prescriptions, which are trained using a mixed-action Soft Actor-Critic algorithm. The task is treated as a single-step contextual bandit. The model is validated against lifestyle medicine prescriptions issued by three certified physicians from Xiangya Hospital. These results demonstrate that offline mixed-action SAC can generate risk-aware lifestyle medicine prescriptions from cross-sectional NHANES data, warranting prospective clinical validation.

Jiacheng Xie, Yang Yu, Ziyang Zhang et al.

Traditional Chinese Medicine (TCM), as an effective alternative medicine, has been receiving increasing attention. In recent years, the rapid development of large language models (LLMs) tailored for TCM has highlighted the urgent need for an objective and comprehensive evaluation framework to assess their performance on real-world tasks. However, existing evaluation datasets are limited in scope and primarily text-based, lacking a unified and standardized multimodal question-answering (QA) benchmark. To address this issue, we introduce TCM-Ladder, the first comprehensive multimodal QA dataset specifically designed for evaluating large TCM language models. The dataset covers multiple core disciplines of TCM, including fundamental theory, diagnostics, herbal formulas, internal medicine, surgery, pharmacognosy, and pediatrics. In addition to textual content, TCM-Ladder incorporates various modalities such as images and videos. The dataset was constructed using a combination of automated and manual filtering processes and comprises over 52,000 questions. These questions include single-choice, multiple-choice, fill-in-the-blank, diagnostic dialogue, and visual comprehension tasks. We trained a reasoning model on TCM-Ladder and conducted comparative experiments against nine state-of-the-art general domain and five leading TCM-specific LLMs to evaluate their performance on the dataset. Moreover, we propose Ladder-Score, an evaluation method specifically designed for TCM question answering that effectively assesses answer quality in terms of terminology usage and semantic expression. To the best of our knowledge, this is the first work to systematically evaluate mainstream general domain and TCM-specific LLMs on a unified multimodal benchmark. The datasets and leaderboard are publicly available at https://tcmladder.com and will be continuously updated.

N. O’grady, P. Barie, J. Bartlett et al.

M. Arrigo, Susanna Price, V. Harjola et al.

Abstract Acute right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale) is a life-threatening condition that may arise in different clinical settings. Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) and are managed initially in emergency departments and later in intensive care units. According to the clinical setting, other specialties are involved (cardiology, pneumology, internal medicine). As such, coordinated delivery of care is particularly challenging but, as shown during the COVID-19 pandemic, has a major impact on prognosis. A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed.

B. Newton, L. Barber, J. Clardy et al.

Min Zhang, Ye Bai, Yutong Wang et al.

BackgroundGeneral obesity is a well-established risk factor for gallstone disease (GSD), but whether central obesity contributes additional independent risk remains controversial. We aimed to comprehensively clarify the effect of body fat distribution on GSD.MethodsWe first investigated the observational association of central adiposity, characterized by waist-to-hip ratio (WHR), with GSD risk using data from UK Biobank (N=472,050). We then explored the genetic relationship using summary statistics from the largest genome-wide association study of GSD (ncase=43,639, ncontrol=506,798) as well as WHR, with and without adjusting for body mass index (BMI) (WHR: n=697,734; WHRadjBMI: n=694,649).ResultsObservational analysis demonstrated an increased risk of GSD with one unit increase in WHR (HR=1.18, 95%CI=1.14-1.21). A positive WHR-GSD genetic correlation (rg =0.41, P=1.42×10-52) was observed, driven by yet independent of BMI (WHRadjBMI: rg =0.19, P=6.89×10-16). Cross-trait meta-analysis identified four novel pleiotropic loci underlying WHR and GSD with biological mechanisms outside of BMI. Mendelian randomization confirmed a robust WHR-GSD causal relationship (OR=1.50, 95%CI=1.35-1.65) which attenuated yet remained significant after adjusting for BMI (OR=1.17, 95%CI=1.09-1.26). Furthermore, observational analysis confirmed a positive association between general obesity and GSD, corroborated by a shared genetic basis (rg =0.40, P=2.16×10-43), multiple novel pleiotropic loci (N=11) and a causal relationship (OR=1.67, 95%CI=1.56-1.78).ConclusionBoth observational and genetic analyses consistently provide evidence on an association of central obesity with an increased risk of GSD, independent of general obesity. Our work highlights the need of considering both general and central obesity in the clinical management of GSD.

Anukul Ghimire, Samveg Shah, Utkarsh Chauhan et al.

Abstract Background There is a lack of contemporary data describing global variations in vascular access for hemodialysis (HD). We used the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to highlight differences in funding and availability of hemodialysis accesses used for initiating HD across world regions. Methods Survey questions were directed at understanding the funding modules for obtaining vascular access and types of accesses used to initiate dialysis. An electronic survey was sent to national and regional key stakeholders affiliated with the ISN between June and September 2022. Countries that participated in the survey were categorized based on World Bank Income Classification (low-, lower-middle, upper-middle, and high-income) and by their regional affiliation with the ISN. Results Data on types of vascular access were available from 160 countries. Respondents from 35 countries (22% of surveyed countries) reported that > 50% of patients started HD with an arteriovenous fistula or graft (AVF or AVG). These rates were higher in Western Europe (n = 14; 64%), North & East Asia (n = 4; 67%), and among high-income countries (n = 24; 38%). The rates of > 50% of patients starting HD with a tunneled dialysis catheter were highest in North America & Caribbean region (n = 7; 58%) and lowest in South Asia and Newly Independent States and Russia (n = 0 in both regions). Respondents from 50% (n = 9) of low-income countries reported that > 75% of patients started HD using a temporary catheter, with the highest rates in Africa (n = 30; 75%) and Latin America (n = 14; 67%). Funding for the creation of vascular access was often through public funding and free at the point of delivery in high-income countries (n = 42; 67% for AVF/AVG, n = 44; 70% for central venous catheters). In low-income countries, private and out of pocket funding was reported as being more common (n = 8; 40% for AVF/AVG, n = 5; 25% for central venous catheters). Conclusions High income countries exhibit variation in the use of AVF/AVG and tunneled catheters. In low-income countries, there is a higher use of temporary dialysis catheters and private funding models for access creation.

Divya Shanmugam, Monica Agrawal, Rajiv Movva et al.

The increased capabilities of generative AI have dramatically expanded its possible use cases in medicine. We provide a comprehensive overview of generative AI use cases for clinicians, patients, clinical trial organizers, researchers, and trainees. We then discuss the many challenges -- including maintaining privacy and security, improving transparency and interpretability, upholding equity, and rigorously evaluating models -- which must be overcome to realize this potential, and the open research directions they give rise to.

Shuang-Kai Yang, Wei-Min Zhang

Utilizing the general theory of open quantum systems to investigate the exact dynamical evolution of simple bilinear systems, we discover a mechanism of the dynamical genesis of quantum entanglement. We focus in detail on the exact quantum evolution dynamics of two photonic modes (or any two bosonic modes) coupled to each other through a linear interaction, as the simplest system of open quantum systems that we have investigated in the last two decades. Such a linear coupling alone fails to produce two-mode entanglement. We also start with an initially separable pure state of the two modes. By solving exactly the quantum equation of motion without relying on the probabilistic interpretation, we find that when the initial state of one mode is different from a coherent state (a minimum uncertainty wave packet with equal variance in the conjugate quadratures that corresponds to a well-defined classically "particle"), the causality in the time-evolution of each mode is internally violated. It also leads to the emergence of quantum entanglement between the two modes. The lack of causality is the nature of statistics. We discover that it is the internal violation of causality in the reduced (subsystem) dynamical evolution that results in the emergence of entanglement and statistic probability in quantum mechanics, even though the dynamical evolution of the whole system completely obeys the deterministic Schrödinger equation. This conclusion is valid for the quantum dynamics of more complicated composite systems. It may provide the fundamental mechanism of the dynamical genesis for both the entanglement and the statistical probability within the deterministic framework of quantum mechanics, which is the longest-standing problem that has not been fully understood since the birth of quantum mechanics.

M. Levaillant, L. Levaillant, N. Lerolle et al.

Background Students’ choice of medical specialties has evolved throughout year, with a growing interest in quality of life and in technological specialties. We investigated the repartition of such choices in the world and its influencing factors with a focus on the gender's influence, for helping policy-makers to deal with medical shortage and territorial to specialty disconnect. Methods A systematic search was conducted on MEDLINE and Scopus from January 2010 to January 2020. Data extraction and analysis followed JBI and PRISMA recommendations. The selected articles had to focus on medical students, detail their choice of specialty, and look for factors influencing their choice. Articles were excluded if they only assessed the attractiveness of a specialty, or evaluated a public policy. This review was registered on PROSPERO, CRD 42020169227. Findings 751 studies were screened, and fifty-four were included. Surgery and internal medicine were the most wanted specialties, both in occidental and non-occidental countries. The main factors influencing the choice of specialty were lifestyle, work-life balance and discipline interest, with variation across different countries. Gender clearly affected this choice with 63.7% of men willing radiology and 14.7% of men in obstetrics and gynecology. Interpretation Influential factors vary with specialty and are affected by the country of residence. Gender has a great impact in students’ willingness to work in specific specialties. Policymakers should adapt their appealing strategies according to the country and the medical discipline concerned. Funding The authors have no support or funding to report.

Conner V Lombardi, Neejad T. Chidiac, Benjamin Record et al.

Background The purpose of this systematic review was to (1) determine the scope of literature measuring USMLE Step 1 and Step 2 CK as predictors or indicators of quality resident performance across all medical specialties and (2) summarize the ability of Step 1 and Step 2 CK to predict quality resident performance, stratified by ACGME specialties, based on available literature. Methods This systematic review was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [16]. The original search strategy surveyed MEDLINE and was adapted to survey Cochrane Library and Embase. A study was deemed eligible if it provided all three of the following relevant information: (a) Step 1 or Step 2 CK as indicators for (b) resident outcomes in (c) any ACGME accredited specialty training program. Results A total of 1803 articles were screened from three separate databases. The 92 included studies were stratified by specialty, with Surgery (21.7% [20/92]), Emergency Medicine (13.0% [12/92]), Internal Medicine (10.9% [10/92]), and Orthopedic Surgery (8.7% [8/92]) being the most common. Common resident performance measures included ITE scores, board certification, ACGME milestone ratings, and program director evaluations. Conclusions Further studies are imperative to discern the utility of Step 1 and Step 2 CK as predictors of resident performance and as tools for resident recruitment and selection. The results of this systematic review suggest that a scored Step 1 dated prior to January 2022 can be useful as a tool in a holistic review of future resident performance, and that Step 2 CK score performance may be an effective tool in the holistic review process. Given its inherent complexity, multiple tools across many assessment modalities are necessary to assess resident performance comprehensively and effectively.

N. Sellke, D. Omil-Lima, Helen H. Sun et al.

The American Urological Association and Endocrine Society published guidelines for the management of testosterone deficiency in 2018. Testosterone prescription patterns have varied widely recently, owing to increased public interest and emerging data on the safety of testosterone therapy. The effect of guideline publication on testosterone prescribing is unknown. Thus, we aimed to assess testosterone prescription trends using Medicare prescriber data. Specialties with over 100 testosterone prescribers from 2016–2019 were analyzed. Nine specialties were included (in order of descending prescription frequency): family practice, internal medicine, urology, endocrinology, nurse practitioners, physician assistants, general practice, infectious disease, and emergency medicine. The number of prescribers grew by a mean of 8.8% annually. There was a significant increase in average claims per provider from 2016 to 2019 (26.4 to 28.7, p  < 0.0001), with the steepest increase occurring between 2017 and 2018 when the guidelines were released (27.2 to 28.1, p  = 0.015). The largest increase in claims per provider was among urologists. Advanced practice providers comprised 7.5% of Medicare testosterone claims in 2016 and 11.6% in 2019. While no causation can be established, these results suggest that professional society guidelines are associated with increasing numbers of testosterone claims per provider, especially among urologists. The changing demographics of prescribers justifies targeted education and further research.