It has long been known from work in both Drosophila and vertebrate systems that the hedgehog signalling pathway is pivotal to embryonic development, but the past 5 years has seen an increase in our understanding of how members of this pathway are crucial to the processes of tumorigenesis. This important link was firmly established with the discovery that mutations in the gene encoding the hedgehog receptor molecule patched are responsible for both familial and sporadic forms of basal cell carcinoma (BCC), as well as a number of other tumour types. It is now known that a number of key members of the hedgehog cascade are involved in tumorigenesis, and dysregulation of this pathway appears to be a key element in the aetiology of a range of tumours.

The role of hedgehog signalling in tumorigenesis.

Cancer Letters

Latent tuberculosis infection (LTBI) is a critical stage of tuberculosis infection in which Mycobacterium tuberculosis (MTB) is dormant and does not cause active disease. Traditionally, the most commonly used clinical methods for diagnosing LTBI have been the tuberculin skin test (TST) and the interferon-gamma release assay (IGRA). Recently, however, novel skin tests, molecular biology techniques, and cytokine biomarkers have been developed. This review summarizes the latest research on the diagnosis of LTBI, highlighting new tools and methods to improve detection and differentiation from active tuberculosis(ATB).

Advances in the Diagnosis of Latent Tuberculosis Infection.

Infection and Drug Resistance

Renal tubular acidoses (RTAs) are a subset of non-anion gap metabolic acidoses that result from complex disturbances in renal acid excretion. Net acid excretion is primarily accomplished through the reclamation of sodium bicarbonate and the buffering of secreted protons with ammonia or dibasic phosphate, all of which require a series of highly complex and coordinated processes along the renal tubule. Flaws in any of these components lead to the development of metabolic acidosis and/or a failure to compensate fully for other systemic acidoses. Identification and diagnosis of RTA can be challenging, and the consequences of untreated RTA can be life-threatening. The use of serum and urinary indices can help elucidate the kidney's capacity to respond to acidemia, characterize these disturbances further, and guide treatment.

Renal Tubular Acidosis: Core Curriculum 2025.

American Journal of Kidney Diseases

Hemorrhagic complications associated with regional anesthesia are extremely rare. The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy reviews the published evidence since 2018 and provides guidance to help avoid this potentially catastrophic complication.The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy uses similar methodology as previous editions but is reorganized and significantly condensed. Therefore, the clinicians are encouraged to review the earlier texts for more detailed descriptions of methods, clinical trials, case series and pharmacology. It is impossible to perform large, randomized controlled trials evaluating a complication this rare; therefore, where the evidence is limited, the authors continue to maintain an 'antihemorrhagic' approach focused on patient safety and have proposed conservative times for the interruption of therapy prior to neural blockade. In previous versions, the anticoagulant doses were described as prophylactic and therapeutic. In this version, we will be using 'low dose' and 'high dose,' which will allow us to be consistent with other published guidelines and more accurately describe the dose in the setting of specific patient characteristics and indications. For example, the same 'high' dose may be used in one patient as a treatment for deep venous thrombosis (DVT) and in another patient as prophylaxis for recurrent DVT. Due to the increasing ability to obtain drug-specific assays, we have included suggestions for when ordering these tests may be helpful and guide practice. Like previous editions, at the end of each recommendation the authors have clearly noted how the recommendation has changed from previous editions.

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition).

Regional Anesthesia and Pain Medicine

Over the past few decades, heart failure with preserved ejection fraction has established itself as an individual clinical entity.&#xa0;Although it is associated with a better prognosis,&#xa0;it offers high resistance to classic treatment techniques, and the frequency of hospitalizations and mortality rates&#xa0;are comparable to cases of heart failure with reduced ejection fraction.&#xa0;Heart failure often leads to death and morbidity, and there has recently been a growing interest in studying the relationship between cardiac and renal function due to epidemiological evidence indicating that even a modest deterioration in renal function is a considerable risk factor in patients with heart failure, myocardial infarction or in the context of cardiovascular surgery. In fact, studies have proven that patients with chronic kidney disease have a cardiovascular risk about 10 times higher than a population of the same age, sex, and race without&#xa0;it. Before writing this review, research literature on heart failure with preserved ejection fraction and chronic kidney disease&#xa0;was reviewed. Studies have shown that in patients with chronic kidney disease, heart failure is mostly caused by the presence of left ventricular diastolic dysfunction,&#xa0;with aggravating comorbidities such as high blood pressure and coronary heart disease.&#xa0;A possible underlying mechanism may be the excessive activation of the renin-angiotensin-aldosterone system, which is known to be a determinant in the onset of profibrotic factors. In fact, it is known that, in patients with chronic heart failure, the renin-angiotensin-aldosterone system is activated, and it has even been shown that the activity of increased plasma renin levels directly contributes to mortality. Angiotensin II promotes cardiac remodeling, and aldosterone may increase myocardial fibrosis, which is a marker of diastolic dysfunction&#xa0;and cardiac necrosis, acting as an endogenous bioactive factor involved in the process of vascular calcification. On the other hand, the development of diastolic dysfunction in patients with chronic kidney disease may result from disorders of metabolism. Besides, evidence indicates that individuals with 25-hydroxyvitamin D deficiency have an increased risk of developing various cardiovascular conditions, such as hypertension, peripheral vascular disease, myocardial infarction, diabetes mellitus, heart failure, and even death.&#xa0;In recent studies, it has been described that the direct effect of vitamin D on cardiomyocytes consists essentially in the acceleration of myocardial relaxation, leading to the hypothesis that it causes a determining effect on diastolic function. Currently, both heart failure with preserved ejection fraction and chronic kidney disease are very prevalent and are closely linked to several other factors, including disturbances in phospho-calcium metabolism and variations in serum vitamin D levels.&#xa0;Although the concept of heart failure began to be explored a few decades ago,&#xa0;further studies are required in order to explain the factors that created the controversy behind the concept of diastolic dysfunction. This review aims precisely to identify the areas that lack further investigation, which can be essential to the development of more effective treatments and subsequently obtain better outcomes.

Diastolic Dysfunction and Renal Disease: Analysis, Mechanisms, and Different Perspectives.

Curēus

To update the 2017 European Alliance of Associations for Rheumatology (EULAR) recommendations for treatment of systemic sclerosis (SSc), incorporating new evidence and therapies.

An international task force was convened in line with EULAR standard operating procedures. A nominal group technique exercise was performed in two rounds to define questions underpinning a subsequent systematic literature review. The evidence derived was discussed and overarching principles, recommendations and future research agenda were iteratively developed with voting rounds.

The task force agreed on 22 recommendations covering 8 clinical/organ domains including Raynaud's phenomenon, digital ulcers, pulmonary arterial hypertension, scleroderma renal crisis, skin fibrosis, interstitial lung disease (ILD), gastrointestinal manifestations and arthritis. Most new recommendations are related to skin fibrosis and ILD. These included novel recommendations for the use of mycophenolate mofetil, nintedanib, rituximab and tocilizumab for the treatment of these crucial disease manifestations. The recommendations also included first-line and second-line interventions, providing increased utility for rheumatology practitioners. Important additions to the future research agenda included consideration of novel interventions for the management of vascular, musculoskeletal and gastrointestinal manifestations and calcinosis, as well as for the local management of digital ulcers.

These updated recommendations include the first set of synthetic and biological targeted therapies recommended for key fibrotic manifestations of SSc as well as first-line combination treatment for newly diagnosed pulmonary artery hypertension and prioritise a new research agenda for the coming years.

EULAR recommendations for the treatment of systemic sclerosis: 2023 update.

Annals of the Rheumatic Diseases

Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10-15%, and around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease.

To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care.

Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost-utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease.

Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion.

Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management.

The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones' condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation.

Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6-15.0) and 4.7 months (interquartile range 2.6-7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference -0.0, 95% confidence interval (-1.7 to 1.7); p -value 0.996; n &#x2005;=&#x2005;203 observation/conservative, n &#x2005;=&#x2005;205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p &#x2005;&lt;&#x2005;0.001 with a similar pattern for the persistent symptoms score. Within-trial cost-utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference -&#xa3;1033). A non-significant quality-adjusted life-year difference of -0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of &#xa3;55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals.

The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery.

This trial is registered as ISRCTN55215960.

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment ; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.

The role of hedgehog signalling in tumorigenesis.

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