Hasil untuk "Specialties of internal medicine"

Gongan Jiang, Weijun Wang, Yuhao Yang et al.

Abstract Objective Information on pathogens and sensitive antibiotics is crucial for treating periprosthetic joint infection (PJI), one of the most severe complications of joint arthroplasty. Lacking this information is not uncommon, and empirical antibiotic treatment should be adopted as a compromise. This study aimed to develop regional-specific antimicrobial regimens and provide a reference for empirical antibiotic treatment for PJI by retrospectively analyzing the pathogen profiles of PJI patients treated in our center and their antibiotic sensitivities. Methods PJI patients treated at our center from January 2018 to December 2024 were retrospectively recruited. Joint aspiration was performed preoperatively to collect synovial fluid for culture and differential cell counting, and synovial tissue samples were obtained intraoperatively from at least three different sites for culture. Patients were diagnosed according to the guidelines of the 2018 International Consensus Meeting and the European Bone and Joint Infection Society. The culture-positive rate, distribution of gram-positive pathogens, methicillin resistance, mixed infections, and multidrug resistance were analyzed. The effective coverage rates of antibiotics were determined, and appropriate empirical antibiotic regimens were proposed. Results A total of 255 PJI patients, comprising 104 males and 151 females, were included; 141 patients had hip PJI, and 114 had knee PJI. Among them, 224 patients (87.8%) had positive culture results. We isolated 335 pathogens, including 218 coagulase-negative staphylococcal infections (65.1%). Staphylococcus epidermidis was the most prevalent pathogen, with 86 isolates (25.7%), followed by Staphylococcus aureus, with 45 isolates (13.4%), and Streptococci, with 20 isolates (6.0%). In hip PJI, the most common pathogens were Staphylococcus epidermidis (50 isolates, 26.6%) and Staphylococcus aureus (30 isolates, 16.0%), and in knee PJI, Staphylococcus epidermidis was predominant (36 isolates, 24.5%). In terms of drug resistance, 48.1% of the staphylococcal strains were methicillin resistant, and 57.6% of the pathogens were multidrug resistant. Staphylococci showed 100% sensitivity to vancomycin and linezolid but were highly resistant to β-lactams and quinolones. In patients with acute postoperative PJI, the combination of vancomycin combined with ceftazidime was 98.4% effective. In patients with chronic PJI, vancomycin combined with imipenem and meropenem achieved effective coverage rates of 94.4% and 95.5%, respectively. The combination of linezolid with meropenem also achieved a 95.5% effective coverage rate. Conclusion Gram-positive bacteria were the predominant pathogens associated with PJI, with high rates of methicillin resistance and multidrug resistance. The combination of vancomycin and meropenem is an empirical antibiotic regimen for culture-negative chronic PJI patients in this region, with the combination of linezolid and meropenem as an alternative. For patients with culture-negative acute postoperative PJI, vancomycin combined with ceftazidime is suggested as the preferred empirical therapy.

D. Kasmi, I. Carmosino, M.L. Bisegna et al.

Background: the low-intensity regimen of venetoclax (VEN) and azacitidine (AZA) demonstrates favorable efficacy and tolerable safety profile in previously untreated elderly pts with acute myeloid leukemia (AML) unfit for intensive chemotherapy. Nonetheless, these benefits are accompanied by significant cytopenias and infectious complications. Methods: in this retrospective study, 65 treatment-naïve elderly pts diagnosed with AML and treated at our institution between 2017 and 2024 were analyzed. Of these, 35 pts received VEN+AZA as first-line treatment (frontline group) and 30 after progression on prior AZA treatment (R/R group). Overall, 58.5% of pts received antimicrobial prophylaxis. Regarding cycle 1 (C1), 41.5% were treated as inpts, while 58.5% as outpts. Results: the most common infections during C1 were FUO (16.9%), pulmonary infections (15.4%) and sepsis (7.7%). Median OS was 17.2 months (range, 8.8-25.6) in pts who received antimicrobial prophylaxis vs. 14.7 (range, 4.7-24.7) in those who did not (p=.97). OS of pts who developed infections was 12 months (range, 8.6-15.5) vs. 46.4 in those who did not (range, 9.8-83.0; p=0.011). Univariate analysis (UVA) showed that acquired infections significantly impacted OS [HR=2.491, p=0.014, (95%CI, 1.3–4.4)], which was confirmed in multivariate analysis (MVA) for OS [HR=2.5, p=.014, (95%CI 1.2–5.2)] and EFS [HR=1.9, p=.053, (95%CI 0.99-3.7)]. Treatment setting was a crucial predictive factor for infection development during C1 of AZA+VEN in both UVA [HR=.257, p=.016, (95%CI 0.08-0.7)] and MVA [HR=.256, p=.035, (95%CI 0.07-0.9)]. In R/R group, 1-year OS was 71% in pts without infections (95%CI, 71-99) vs. 63% (95%CI, 43-91) in those with (p= 0.027). 1-year EFS was 71% (95%CI, 51-99) vs. 50% (95%CI, 31-82), respectively (p=0.045). 3-month cumulative incidence of infection in frontline group was 79% (95%CI, 51-92) in inpts vs. 50% (95%CI, 23-72) in outpts (p=.043). In R/R group was 75% (95%CI, 36-92) in unfit pts vs. 28% (95%CI, 9.7-50) in those fit (p=.002). In pts <75 years old was 63% (95%CI, 37-81) vs. 75% (95%CI, 2.5-46) in those ≥75 years (p=.0021). Pts with a PLT count at C1d28 ≥100x109/L developed fewer infections compared to those with lower counts [23%, (95%CI, 5.1-49) vs. 65%, (95%CI, 36-83), p=.023]. Conclusions: performing C1 in an inpatient setting is associated with higher risk of infections and poorer survival outcomes. PLT recovery at day 28 plays a protective role, particularly in R/R group.

Elisa Cassart, Joan Miquel, Fernando Santana et al.

Assia Hijazi, Jérôme Galon

In clinical practice, the administration of adjuvant chemotherapy (ACT) following tumor surgical resection raises a critical dilemma for stage II colon cancer (CC) patients. The prognostic features used to identify high-risk CC patients rely on the pathological assessment of tumor cells. Currently, these factors are considered for stratifying patients who may benefit from ACT at early CC stages. However, the extent to which these factors predict clinical outcomes (i.e. recurrence, survival) remains highly controversial, also uncertainty persists regarding patients’ response to treatment, necessitating further investigation. Therefore, an imperious need is to explore novel biomarkers that can reliably stratify patients at risk, to optimize adjuvant treatment decisions. Recently, we evaluated the prognostic and predictive value of Immunoscore (IS), an immune digital-pathology assay, in stage II CC patients. IS emerged as the sole significant parameter for predicting disease-free survival (DFS) in high-risk patients. Moreover, IS effectively stratified patients who would benefit most from ACT based on their risk of recurrence, thus predicting their outcomes. Notably, our findings revealed that digital IS outperformed the visual quantitative assessment of the immune response conducted by expert pathologists. The latest edition of the WHO classification for digestive tumor has introduced the evaluation of the immune response, as assessed by IS, as desirable and essential diagnostic criterion. This supports the revision of current cancer guidelines and strongly recommends the implementation of IS into clinical practice as a patient stratification tool, to guide CC treatment decisions. This approach may provide appropriate personalized therapeutic decisions that could critically impact early-stage CC patient care.

Nai-Chien Huan, Larry Ellee Nyanti, Xin Ying Lee et al.

Brown-colored pleural effusion is rare and may result from high bilirubin levels such as bilothorax (often described as a pleural fluid-to-serum bilirubin ratio of > 1.0). We describe four patients with malignant pleural effusion that appeared macroscopically brown with a pleural fluid-to-serum bilirubin ratio between 3.7 and 16.2. All had metastatic adenocarcinomas; three were from lung and one from gastric origin. None demonstrated clear pleurobiliary fistulas on investigations. Postulates for the development of brown effusion include heme oxygenase 1 overexpression in malignant cells situated in the pleura, intrapleural hemolysis, passive movement of bile through microscopic diaphragmatic pores, and drainage of biliary fluid into the pleural lymphatics.

Yufei Ruan, Zhengwang Wen, Ke Chen et al.

Human cytomegalovirus (HCMV) infection is globally distributed, and the liver is one of the major targeting organs. So far, the mechanisms for cell and organ damage have not fully been elucidated and the treatments for the infection are mainly at symptoms. IL-37 has shown a protective role in certain inflammatory diseases. In the present study, potential protective effect of exogenous IL-37 on murine cytomegalovirus- (MCMV-) infected hepatitis was evaluated through analyses of serum transaminases, the liver histopathology and cytokine expression, and functional state of dendritic cells (DCs) and regulatory T cells (Tregs). These analyses showed a significant decrease in serum transaminase levels and a lower Ishak histopathologic score at the early stage of MCMV-infected mice with exogenous IL-37 pretreatment. The frequencies of MHC-Ⅱ, CD40, CD80, and CD86 positive DCs in the liver and spleen were decreased significantly at 7 days postinfection (dpi) in MCMV-infected mice with IL-37 pretreatment when compared with those without the pretreatment, while the total number of DCs in the liver was reduced in IL-37-pretreated mice. The induction of Tregs in the spleen was enhanced at dpi 3 with IL-37 pretreatment in MCMV-infected mice. The mRNA expression levels of cytokines in the liver were decreased significantly (IL-1β, IL-6, IL-10, IL-4) or to some extent (TGF-β and TNF-α). The present study suggested that exogenous IL-37 can alleviate MCMV-infected hepatitis, likely through reduced DCs and induced Tregs with a weaker cytokine storm, demonstrating its potential value in clinical management for HCMV-infected hepatitis.

Jian Huang

BackgroundRetinal vein occlusion (RVO) is a common retinal vascular disease that can cause severe visual impairment. Many observational studies have shown that type 2 diabetes (T2DM) is associated with RVO, but it remains unknown if the association is causal. The present study aimed to perform Mendelian randomization (MR) analyses to evaluate the causal contribution of genetically predicted T2DM to RVO.MethodsWe obtained summary-level data from a genome-wide association study meta-analysis including 48,286 cases and 250,671 controls for T2DM and from a genome wide association study of 372 cases and 182,573 controls in the FinnGen project for RVO. To verify the robustness of the results, an independent validation dataset for T2DM (12,931 cases and 57,196 controls) was used. In addition to the main MR analysis using the inverse variance weighted (fixed effect) approach, sensitivity analyses and multivariable MR adjusting for common risk factors of RVO were conducted.ResultsGenetically predicted T2DM was found to be causally associated with RVO risk (odds ratio (OR)=2.823, 95% confidence interval (CI): 2.072-3.847, P=4.868×10-11). This association was supported by sensitivity analyses using the weighted median (OR=2.415, 95% CI: 1.411-4.132, P=1.294×10-3), weighted mode (OR=2.370, 95% CI: 1.321-4.252, P=5.159×10-3), maximum likelihood (OR=2.871, 95% CI: 2.100-3.924, P=3.719×10-11), MR-PRESSO (OR=2.823, 95% CI: 2.135-3.733, P=5.150×10-10), and MR-Egger (OR=2.441, 95% CI: 1.149-5.184, P=2.335×10-2) methods. In addition, this association persisted in multivariable MR after accounting for common RVO risk factors (OR=1.748, 95% CI: 1.238-2.467, P=1.490×10-3). The MR analyses using the validation dataset obtained consistent results.ConclusionThis study indicates that genetically predicted T2DM may have a causal contribution to RVO. Future studies are required to elucidate the underlying mechanisms.

Lucélia Luna Melo-Diaz, George Alvicio Kieling

Daniel J. Watford, Glenn M. Chertow

Xinting Wang, Chunyan Zhang, Shuhe Wang et al.

To date, no reports have linked the multifunctional protein, staphylococcal nuclease domain-containing protein 1 (SND1), to host defense against intracellular infections. In this study, we investigated the role and mechanisms of SND1, by using SND1 knockout (SND1-/-) mice, in host defense against the lung infection of Chlamydia muridarum, an obligate intracellular bacterium. Our data showed that SND1-/- mice exhibited significantly greater body weight loss, higher organism growth, and more severe pathological changes compared with wild-type mice following the infection. Further analysis showed significantly reduced Chlamydia-specific Th1/17 immune responses in SND1-/- mice after infection. Interestingly, the dendritic cells (DCs) isolated from SND1-/- mice showed lower costimulatory molecules expression and IL-12 production, but higher IL-10 production compared with those from wild-type control mice. In the DC-T cell co-culture system, DCs isolated from SND1-/- infected mice showed significantly reduced ability to promote Chlamydia-specific IFN-γ producing Th1 cells but enhanced capacity to induce CD4+T cells into Foxp3+ Treg cells. Adoptive transfer of DCs isolated from SND1-/- mice, unlike those from wild-type control mice, failed to protect the recipients against challenge infection. These findings provide in vivo evidence that SND1 plays an important role in host defense against intracellular bacterial infection, and suggest that SND1 can promote Th1/17 immunity and inhibit the expansion of Treg cells through modulation of the function of DCs.

Ioannis G. Lempesis, Gijs H. Goossens, Konstantinos N. Manolopoulos

Adipose tissue blood flow (ATBF) is an important determinant of adipose tissue (AT) function. 133Xenon wash-out technique is considered the gold-standard for human ATBF measurements. However, decreasing 133Xenon clinical use and costly production and preservation, make alternative (non-invasive) methods necessary. Here, we explored percutaneous Doppler ultrasound as a proxy method to quantify intravascular subcutaneous abdominal and femoral ATBF in humans (n= 17). Both fasting ATBF and the postprandial increase in ATBF were significantly higher in abdominal compared to femoral AT. Although anatomical variations in vein location and depot thickness may impact feasibility, we demonstrate that Doppler ultrasound detects the expected depot-differences and postprandial increase in ATBF in healthy individuals. This method warrants further investigation in other populations and metabolic conditions.

Anirban Majumder, Sudip Chatterjee, Soumyabrata Roy Chaudhuri et al.

Context: Gender incongruent individuals are exposed to unique stressors as a result of their minority social position. Poor social support has a further adverse impact on the lives and wellbeing of gender incongruent individuals. There is a paucity of scientific data from India on the socioeconomic status (SES) of gender incongruent community. Aims: Aim of the study is to understand and estimate the social support, wellbeing, and SES of gender incongruent individuals in Eastern India. Subjects and Methods: Data of 120 gender incongruent patients from the endocrinology outpatient department of a tertiary care hospital in eastern India were collected. We looked at demographic characteristics, social support, underlying psychiatric comorbidities, and SES. SES was calculated by the Kuppuswamy's socioeconomic status (KSS) scale based on occupation, education, and income. Statistical Analysis Used: Microsoft Word and Excel were used to generate tables. Results: Most of the gender incongruent individuals were transfeminine. Almost half of them had no history of addiction. Most of them had good support from family and friends and very few (only 3%) had mental health problems. Calculation by KSS scale showed most of the study population lay in the upper middle or lower middle socioeconomic class. Conclusions: Strong support from friends and family appears a key factor for protection against psychiatric comorbidities and an all-round impact on the lives and wellbeing of the study population.

Kwangsoon Kim, Jin Kyong Kim, Cho Rok Lee et al.

Background: The 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) tumor-node-metastasis (TNM) staging system was released with major revisions. The purpose of this retrospective study was to investigate differences between the 7th and 8th editions of the AJCC/UICC TNM staging system and to compare the predictability of prognosis between the two staging systems with patients who underwent thyroidectomy for differentiated thyroid cancer (DTC) at a single institution. Methods: A total of 3238 patients underwent thyroid operation from January 2002 to December 2006 at Yonsei University Hospital (Seoul, Korea), of which 2294 with complete clinical data and sustained follow up were enrolled. Clinicopathologic features and TNM staging by applying the 7th and 8th editions of the AJCC/UICC were analyzed retrospectively by the complete review of medical charts and pathology reports of patients. Mean follow-up duration was 132.9 ± 27.9 months. Results: A significant number of T3 patients were downstaged to T1 (838, 36.5%) and T2 (122, 5.3%). After applying the 8th edition of the AJCC/UICC TNM staging system, the number of stage I patients increased significantly from 1434 (62.5%) to 2058 (89.7%), whereas numbers of stage III and IV patients decreased significantly from 644 (28.1%) to 33 (1.4%) and from 199 (8.7%) to 17 (0.7%), respectively. According to Kaplan–Meier survival analyses and values of the Harrell’s c-index and integrated area under the curve (iAUC), the 8th edition has significantly better predictive performance for disease-free survival (DFS) and disease-specific survival (DSS) than the 7th edition. Conclusions: A significant population was downstaged after applying the 8th edition of the AJCC/UICC TNM staging system, and the 8th edition provided significantly better accuracy in predicting DFS and DSS in patients with DTC.

Robin Jacob, MD, Paolo Strati, MD, Nicolas Palaskas, MD et al.

A 66-year-old woman with follicular lymphoma on lenalidomide and rituximab presented with chest pain. High-sensitivity troponin T peaked at 7,566 ng/l. Cardiac biopsy revealed extensive inflammation consistent with medication-induced myocarditis. Lenalidomide was stopped with improvement in troponins and patient was initiated on high-dose corticosteroid therapy. (Level of Difficulty: Intermediate.)

María Dolores Arenas Jiménez, Mónica Navarro García, Encarnación Serrano Reina et al.

Resumen: Introducción: Las actividades instrumentales de la vida diaria (AIVD) requieren un mayor nivel de autonomía personal e interacción con el entorno que las actividades básicas de la vida diaria (ABVD). Pocos estudios analizan el déficit funcional en AIVD. La detección temprana del déficit es importante, pues una acción temprana puede retrasar la evolución del proceso de dependencia. Objetivo: El objetivo de este estudio fue conocer la prevalencia de déficit funcional en AIVD de pacientes en hemodiálisis (HD), su relación con el déficit funcional en la ABVD y su influencia en la calidad de vida relacionada con la salud (CVRS). Métodos: Estudio transversal en 66 pacientes en HD. Se utilizaron diferentes escalas: Lawton y Brody (dependencia AIVD), Delta (dependencia ABVD), y COOP-WONCA (CVRS). Se recogieron datos clínicos (edad, sexo, etiología de la ERC, meses en HD, estado civil, situación laboral). Resultados: El 80,3% de los pacientes estudiados tenía algún grado de dependencia para el AIVD (57,5% en grado moderado/severo) y 40,8% para el ABVD (9% en grado moderado/severo). Ambos tipos de dependencia mostraron correlación (R: –0.583; p = 0,000). La edad y la situación laboral influyen en la dependencia de las AIVD y las ABVD. Los pacientes con mayor dependencia de la AIVD tuvieron una peor CVRS (p < 0,000) con mayores diferencias en las dimensiones: «actividades diarias», «actividades sociales» y «apoyo social». Conclusiones: Los pacientes de HD presentan más dependencia a las AIVD que a las ABVD, y con mayor severidad y ambos tipos de dependencia influyen sobre la CVRS. Detectar precozmente la discapacidad en las AIVD puede servir para iniciar programas de intervención y prevenir, revertir o retrasar la progresión. Abstract: Introduction: Instrumental Activities of Daily Life (IADL) requires a higher level of personal autonomy and interaction with the environment than the basic activities of daily life (BADL). Few studies analyze the deficit on IADL. Early detection is important because an early action can delay the evolution of the dependency process. Aim: to know the prevalence of functional deficit in IADL of hemodialysis patients, its relationship with the functional deficit in the BADL and its influence on the health related quality of life (HRQoL). Methods: Cross-sectional study in 66 patients on HD. Different scales were used: Lawton and Brody (AIVD dependency), Delta (BADL dependency), and COOP-WONCA (HRQOL). Clinical data were collected (age, sex, CKD etiology, months in HD, marital status, employment situation). Results: 80.3% of the patients had some degree of dependence for the IADL (57.5% in moderate/severe degree) and 40.8% for the BADL (9% in moderate/severe degree). There was a correlation between dependence to the BADL and AIVD. Age and employment status influence the dependence on IADL and BADL. Patients with greater dependence on IADL had worse HRQoL (P < .000). The dimensions in which they showed greater differences were “Daily activities”, “Social activities” and “Social support”. Conclusions: HD patients are more dependent on IADL than on ADL and with a higher degree of severity and the level of dependence in both types of activities has important influence on HRQoL. Early detection of the occurrence of disability in the realization of IADL can be used to initiate intervention programs that help to prevent, reverse or delay the progression. Palabras clave: Actividades instrumentales de la vida diarias, Actividades básicas de la vida diaria, Hemodiálisis, Calidad de vida relacionada con la salud, Terapia ocupacional, Keywords: Instrumental activities of daily living, Basical activities of daily living, Hemodialysis, Health-related quality of life, Occupational therapy

Giovanna Ferraioli, Valeria Calcaterra, Raffaella Lissandrin et al.

Abstract Background To assess the clinical validity of controlled attenuation parameter (CAP) in the diagnosis of hepatic steatosis in a series of overweight or obese children by using the imperfect gold standard methodology. Methods Consecutive children referred to our institution for auxological evaluation or obesity or minor elective surgery were prospectively enrolled. Anthropometric and biochemical parameters were recorded. Ultrasound (US) assessment of steatosis was carried out using ultrasound systems. CAP was obtained with the FibroScan 502 Touch device (Echosens, Paris, France). Pearson’s or Spearman’s rank correlation coefficient were used to test the association between two study variables. Optimal cutoff of CAP for detecting steatosis was 249 dB/m. The diagnostic performance of dichotomized CAP, US, body mass indexes (BMI), fatty liver index (FLI) and hepatic steatosis index (HSI) was analyzed using the imperfect gold standard methodology. Results Three hundred five pediatric patients were enrolled. The data of both US and CAP were available for 289 children. Steatosis was detected in 50/289 (17.3%) children by US and in 77/289 (26.6%) by CAP. A moderate to good correlation was detected between CAP and BMI (r = 0.53), FLI (r = 0.55) and HSI (r = 0.56). In obese children a moderate to good correlation between CAP and insulin levels (r = 0.54) and HOMA-IR (r = 0.54) was also found. Dichotomized CAP showed a performance of 0.70 (sensitivity, 0.72 [0.64–0.79]; specificity, 0.98 [0.97–0.98], which was better than that of US (performance, 0.37; sensitivity, 0.46 [0.42–0.50]; specificity, 0.91 [0.89–0.92]), BMI (performance, 0.22; sensitivity, 0.75 [0.73–0.77]; specificity, 0.57 [0.55–0.60]) and FLI or HSI. Conclusions For the evaluation of liver steatosis in children CAP performs better than US, which is the most widely used imaging technique for screening patients with a suspicion of liver steatosis. A cutoff value of CAP of 249 dB/m rules in liver steatosis with a very high specificity.

Joana Carmo, Susana Marques, Iolanda Chapim et al.

In recent years, significant advances in the treatment of Clostridium difficile infection (CDI) have risen. We review the most relevant updated recommendations in the current standard of care of CDI and discuss emerging therapies, including antibiotic, alternative therapies (probiotics, toxin-binding resins, immunotherapy) and new data on fecal transplantation. Upcoming surgical options and other rescue therapies for severe refractory disease are also addressed. Although oral metronidazole is a first-line therapy for non-severe CDI, emerging data have demonstrated its inferiority relatively to vancomycin, particularly in the setting of recurrent and/or severe infection. After a CDI recurrence for the first time, fidaxomicin has been shown to be associated with lower likelihood of CDI recurrence compared to vancomycin. Fecal transplantation is now strongly recommended for multiple recurrent CDI and may have a role in refractory disease. Oral, frozen stool capsules may simplify fecal transplantation in the future, with preliminary promising results. Diverting loop ileostomy combined with colonic lavage is a potential alternative to colectomy in severe complicated CDI. Potential alternative therapies requiring further investigation include toxin-binding resins and immunotherapy.

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V. A. Kokorin, N. V. Sytnik, A. V. Dudareva et al.

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H. Gough