Alpha-lipoic acid for diabetic peripheral neuropathy.

BACKGROUND: Diabetic peripheral neuropathy (DPN) is a frequent complication in people living with type 1 or type 2 diabetes. There is currently no effective treatment for DPN. Although alpha-lipoic acid (ALA, also known as thioctic acid) is widely used, there is no consensus about its benefits and harms. OBJECTIVES: To assess the effects of alpha-lipoic acid as a disease-modifying agent in people with diabetic peripheral neuropathy. SEARCH METHODS: On 11 September 2022, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and two clinical trials registers. We also searched the reference lists of the included studies and relevant review articles for additional references not identified by the electronic searches. SELECTION CRITERIA: We included randomised clinical trials (RCTs) that compared ALA with placebo in adults (aged 18 years or older) and that applied the study interventions for at least six months. There were no language restrictions. DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. The primary outcome was change in neuropathy symptoms expressed as changes in the Total Symptom Score (TSS) at six months after randomisation. Secondary outcomes were change in neuropathy symptoms at six to 12 months and at 12 to 24 months, change in impairment, change in any validated quality of life total score, complications of DPN, and adverse events. We assessed the certainty of the evidence using GRADE. MAIN RESULTS: Our analysis incorporated three trials involving 816 participants. Two studies included people with type 1 or type 2 diabetes, while one study included only people with type 2 diabetes. The duration of treatment was between six months and 48 months. We judged all studies at high risk of overall bias due to attrition. ALA compared with placebo probably has little or no effect on neuropathy symptoms measured by TSS (lower score is better) after six months (mean difference (MD) -0.16 points, 95% confidence interval (CI) -0.83 to 0.51; 1 study, 330 participants; moderate-certainty evidence). The CI of this effect estimate did not contain the minimal clinically important difference (MCID) of 0.97 points. ALA compared with placebo may have little or no effect on impairment measured by the Neuropathy Impairment Score-Lower Limbs (NIS-LL; lower score is better) after six months (MD -1.02 points, 95% CI -2.93 to 0.89; 1 study, 245 participants; low-certainty evidence). However, we cannot rule out a significant benefit, because the lower limit of the CI surpassed the MCID of 2 points. There is probably little or no difference between ALA and placebo in terms of adverse events leading to cessation of treatment within six months (risk ratio (RR) 1.48, 95% CI 0.50 to 4.35; 3 studies, 1090 participants; moderate-certainty evidence). No studies reported quality of life or complications associated with DPN. AUTHORS' CONCLUSIONS: Our analysis suggests that ALA probably has little or no effect on neuropathy symptoms or adverse events at six months, and may have little or no effect on impairment at six months. All the studies were at high risk of attrition bias. Therefore, future RCTs should ensure complete follow-up and transparent reporting of any participants missing from the analyses.

Chronic pain, a narrative review for the internist in 2024.

Chronic pain is a complex and pervasive condition that profoundly affects individuals physically, emotionally, and socially. This narrative review aims to provide internists and healthcare professionals with a comprehensive overview of chronic pain, its various types, pathophysiology, epidemiology, clinical presentation, evaluation tools, and the burden it imposes on patients. We discuss the importance of recognizing chronic pain as a legitimate condition and the need for a compassionate, individualized approach to management. The review highlights the role of both pharmacological and non-pharmacological interventions in treating chronic pain, emphasizing the value of reducing pain, improving function, enhancing quality of life, and minimizing medication dependence. Additionally, we touch upon the promising future of pain treatment, including advancements in technology and personalized medicine. While not a comprehensive systematic review, this article serves as a valuable resource for healthcare providers seeking to understand, manage, and treat chronic pain effectively in their daily practice.

Antibiotic Prescription and In-Hospital Mortality in COVID-19: A Prospective Multicentre Cohort Study.

BACKGROUND: Since the beginning of the COVID-19 pandemic, empiric antibiotics (ATBs) have been prescribed on a large scale in both in- and outpatients. We aimed to assess the impact of antibiotic treatment on the outcomes of hospitalised patients with moderate and severe coronavirus disease 2019 (COVID-19). METHODS: We conducted a prospective multicentre cohort study in six clinical hospitals, between January 2021 and May 2021. RESULTS: We included 553 hospitalised COVID-19 patients, of whom 58% (311/553) were prescribed antibiotics, while bacteriological tests were performed in 57% (178/311) of them. Death was the outcome in 48 patients-39 from the ATBs group and 9 from the non-ATBs group. The patients who received antibiotics during hospitalisation had a higher mortality (RR = 3.37, CI 95%: 1.7-6.8), and this association was stronger in the subgroup of patients without reasons for antimicrobial treatment (RR = 6.1, CI 95%: 1.9-19.1), while in the subgroup with reasons for antimicrobial therapy the association was not statistically significant (OR = 2.33, CI 95%: 0.76-7.17). After adjusting for the confounders, receiving antibiotics remained associated with a higher mortality only in the subgroup of patients without criteria for antibiotic prescription (OR = 10.3, CI 95%: 2-52). CONCLUSIONS: In our study, antibiotic treatment did not decrease the risk of death in the patients with mild and severe COVID-19, but was associated with a higher risk of death in the subgroup of patients without reasons for it.

In-Hospital Antibiotic Use for COVID-19: Facts and Rationales Assessed through a Mixed-Methods Study.

It is well known that during the coronavirus disease 2019 (COVID-19) pandemic, antibiotics were overprescribed. However, less is known regarding the arguments that have led to this overuse. Our aim was to understand the factors associated with in-hospital antibiotic prescription for COVID-19, and the rationale behind it. We chose a convergent design for this mixed-methods study. Quantitative data was prospectively obtained from 533 adult patients admitted in six hospitals (services of internal medicine, infectious diseases and pneumology). Fifty-six percent of the patients received antibiotics. The qualitative data was obtained from interviewing 14 physicians active in the same departments in which the enrolled patients were hospitalized. Thematic analysis was used for the qualitative approach. Our study revealed that doctors based their decisions to prescribe antibiotics on a complex interplay of factors regarding the simultaneous appearance of consolidation on the chest computer tomography together with a worsening of clinical conditions suggestive of bacterial infection and/or an increase in inflammatory markers. Besides these features which might suggest bacterial co-/suprainfection, doctors also prescribed antibiotics in situations of uncertainty, in patients with severe disease, or with multiple associated comorbidities.

Contribution of an Early Internal Medicine Rotation to the Clinical Reasoning Learning for Young Residents.

Clinical reasoning is the cornerstone of medical practice, and achieving this competence depends on a large number of factors. Internal medicine departments provide junior doctors with plentiful and varied patients, offering a comprehensive basis for learning clinical reasoning. In order to evaluate the usefulness of an early rotation at internal medicine departments, we compared, via script concordance tests, the evolution of residents' clinical reasoning after an initial internal medicine rotation compared to rotations through other medical specialties. Twenty-two residents were tested after six months of their internal medicine rotation and compared to twenty-five residents that had the first rotation in another specialty (control). We showed a significant difference in the improvement of the script concordance tests scores (p=0.015) between the beginning and the end of their first rotation between the internal medicine and the control groups, and this implies the lower improvement of clinical reasoning skills and spontaneous learning slope of the junior doctors in other departments.

Sepsis, a 2020 review for the internist.

Sepsis is an overwhelming reaction to infection that comes with high morbidity and mortality, which requires urgent interventions in order to improve outcomes. Surviving Sepsis is an international campaign that aims to improve sepsis outcomes. The 2016 guideline modifies the previous definition of sepsis and proposes some specific diagnostic and therapeutic measures, such as the protocolized use of fluid resuscitation and antibiotics. We aim to summarize the main recommendations of the 2016 guideline that are relevant to the internist and evidence-base update them to the year 2020. In the current context, this review doesn't address patients affected by SARS-COV2 induced disease.

The Romanian Society of Internal Medicine's Choosing Wisely Campaign.

Quality of care in medicine is not necessarily proportional to quantity of care and excess is often useless or even more, potentially detrimental to our patients. Adhering to the European Federation of Internal Medicine's initiative, the Romanian Society of Internal Medicine (SRMI) launched the Choosing Wisely in Internal Medicine Campaign, aiming to cut down diagnostic procedures or therapeutics overused in our country. A Working Group was formed and from 200 published recommendations from previous international campaigns, 36 were voted as most important. These were submitted for voting to the members of the SRMI and posted on a social media platform. After the two voting rounds, the top six recommendations were established. These were: 1. Stop medicines when no further benefit is achieved or the potential harms outweigh the potential benefits for the individual patient. 2. Don't use antibiotics in patients with recent C. difficile without convincing evidence of need. 3. Don't regularly prescribe bed rest and inactivity following injury and/or illness unless there is scientific evidence that harm will result from activity. Promote early mobilization. 4. Don't initiate an antibiotic without an identified indication and a predetermined length of treatment or review date. 5. Don't prescribe opioids for treatment of chronic or acute pain for sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment. 6. Transfuse red cells for anemia only if the hemoglobin concentration is less than 7 g/dL or if the patient is hemodynamically unstable or has significant cardiovascular or respiratory comorbidity. Don't transfuse more units of blood than absolutely necessary.

Cellular Interactions in the Human Fatty Liver.

Non-alcoholic steatohepatitis morbidity and mortality is on the rise due to the obesity pandemic. Its pathophysiology is not well understood and implies complex interactions between local hepatic cells populations, adipocytes, immune effectors that lead to hepatic lipid excess, lipotoxicity, cellular stress and inflammation, as well as programmed cell death. A better understanding of these pathogenic interactions would allow better identification of therapeutic targets in a disease that has no known pharmacological therapy until now.

Specific Factors That Influence Adherence to Beta Blocker Treatment in Primary Prevention of Variceal Bleeding in Cirrhotic Romanian Patients. a Proof of Concept Qualitative Study.

Adherence to medical treatment in chronic patients challenging, especially in primary prevention where the benefit is not directly perceived by the patient. Through the directed interview of this qualitative study we assessed some specific factors that intervene in beta-blockers adherence in cirrhotic patients with oesophageal varices in primary prevention in Romanian. We identified that the most important modifiable extrinsic factor that influences adherence is the confidence in medicine. The intensely negative perception of the disease seemed to be another major driver of adherence.