Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal

Background and aim

The number of elderly patients with biliary stones is increasing. Endoscopic retrograde cholangiography (ERCP) is considered to be an effective treatment for biliary stones. Having a sound knowledge of the risk factors can help reduce the incidence and severity of complications for ERCP. Furthermore, limited research has been published on patients aged over 85 years undergoing endoscopic biliary stone removal. This study aims to determine the risk factors that lead to complications of ERCP in patients over 85 years of age.

Methods

This was a single-center retrospective study. We analyzed 156 patients aged ≥ 85 years with biliary stones who underwent their first ERCP at Chinese PLA General Hospital from February 2002 to March 2021. Logistic regression models were employed to identify the independent risk factors for complications.

Results

A total of 13 patients (8.3%) had complications. Thereinto, pancreatitis, cholangitis, bleeding, and other complications occurred in 4 cases (2.6%), 1 cases (0.6%), 4 cases (2.6%), and 4 cases (2.6%), respectively. There was no perforation or death related to ERCP. Independent risk factors for complications were acute biliary pancreatitis (ABP) (P = 0.017) and Charlson Comorbidity Index (CCI) (P = 0.019). Significantly, reasons for incomplete stone removal at once were large stone (>10 mm) (P < 0.001) and higher acute physiology and chronic health evaluation scoring system (APACHE-II) (P = 0.005).

Conclusions

ERCP was recommended with caution in patients ≥ 85 years of age with ABP or higher CCI undergoing endoscopic biliary stone removal. In patients with ABP without cholangitis or biliary obstruction we recommend against urgent (within 48 h) ERCP. Patients with higher CCI who can tolerate ERCP can undergo rapid ERCP biliary stenting or nasobiliary implantation with later treatment of stones, and patients who cannot tolerate ERCP are treated promptly with PTCD and aggressive conservative treatment.

18F-FDG PET/CT Imaging of G-CSF-Producing Dedifferentiated Liposarcoma

ABSTRACT

Granulocyte colony-stimulating factor (G-CSF)-producing tumors are malignant tumors associated with a poor prognosis, and G-CSF-producing liposarcoma is particularly rare. We report a case of G-CSF-producing dedifferentiated liposarcoma. 18F-FDG PET/CT showed abnormal 18F-FDG uptake throughout the bone marrow and in the primary site. When a diffuse bone marrow 18F-FDG uptake was observed on 18F-FDG PET/CT, G-CSF-producing dedifferentiated liposarcoma should be included in the differential diagnosis.

Management of COVID-19 patients with chronic liver diseases and liver transplants

The epidemic of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has increasingly attracted worldwide concern. Liver damage or dysfunction occurred in patients with COVID-19 (mainly characterized by moderately elevated serum aspartate aminotransferase levels). However, it is not yet clear whether the COVID-19-related liver injury is mainly caused by the virus infection, potentially hepatotoxic drugs, or other coexisting conditions. Progression of pre-existing chronic liver disease (CLD) may be the underlying mechanism of liver injury. Although COVID-19 patients with CLD, such as nonalcoholic fatty liver disease, liver cirrhosis, and liver cancer, have been deemed at increased risk for serious illness in many studies, little is known about the impact of CLD on the natural history and outcome of COVID-19 patients. Thereby, based on the latest evidence from case reports and case series, this paper discusses the clinical manifestations, treatment, prognosis, and management of the COVID-19 patients with different CLD. This article also reviews the effect of COVID-19 on liver transplantation patients (LT), hoping to work for future prevention, management, and control measures of COVID-19. However, due to the lack of relevant research, most of them are still limited to the theoretical stage, further study of COVID-19 and CLD needs to be improved in the future.

Complete remission in leptomeningeal metastasis of NSCLC with rare EGFR-SEPT14 fusion treated with osimertinib combined with intrathecal chemotherapy with pemetrexed

Leptomeningeal metastasis (LM) is one of the most serious complications of non-small cell lung cancer (NSCLC) without standard treatment guidelines and is always accompanied by poor prognosis. Identifying the types of gene mutations is essential to improve the outcome, and an increasing number of rare epidermal growth factor receptor (EGFR) mutations are revealed by next-generation sequencing (NGS). Here, we describe a case of a 56-year-old man who was diagnosed with lung adenocarcinoma and received thoracoscopic resection in May 2015. One year later, LM was confirmed by positive cerebrospinal fluid cytology. Given the existence of EGFR exon 19 deletions, erlotinib was implemented and achieved a short response for 10 months. Then the systemic therapy was changed to osimertinib and obtained clinical remission for 25 months. Owing to the resurgence of violent headache, retching and vomiting, NGS of cerebrospinal fluid was performed and two rare EGFR-SEPT14 fusions were found. Osimertinib combined bevacizumab, chemotherapy (carboplatin and abraxane) and dacomitinib were implemented in turn but ineffective. Thus, osimertinib combined intrathecal chemotherapy with pemetrexed were carried out and gained a complete remission of neurologic symptoms, stable lesions and long-term survival without notable side effects. This study presented the first case of NSCLC-LM harboring particular EGFR-SEPT14 fusions, who showed a durable response to osimertinib and intrathecal pemetrexed, providing a potential therapeutic option for NSCLC-LM patients with this particular mutation.

Role and Regulation of Wnt/β-Catenin in Hepatic Perivenous Zonation and Physiological Homeostasis

Metabolic heterogeneity or functional zonation is a key characteristic of the liver that allows different metabolic pathways to be spatially regulated within the hepatic system and together contribute to whole body homeostasis. These metabolic pathways are segregated along the portocentral axis of the liver lobule into three hepatic zones: periportal, intermediate or midzonal, and perivenous. The liver performs complementary or opposing metabolic functions within different hepatic zones while synergistic functions are regulated by overlapping zones, thereby maintaining the overall physiological stability. The Wnt/β-catenin signaling pathway is well known for its role in liver growth, development, and regeneration. In addition, the Wnt/β-catenin pathway plays a fundamental and dominant role in hepatic zonation and signals to orchestrate various functions of liver metabolism and pathophysiology. The β-catenin protein is the central player in the Wnt/β-catenin signaling cascade, and its activation is crucial for metabolic patterning of the liver. However, dysregulation of Wnt/β-catenin signaling is also implicated in different liver pathologies, including those associated with metabolic syndrome. β-Catenin is preferentially localized in the central region of the hepatic lobule surrounding the central vein and regulates multiple functions of this region. This review outlines the role of Wnt/β-catenin signaling pathway in controlling the different metabolic processes surrounding the central vein and its relation to liver homeostasis and dysfunction.

OUP accepted manuscript

Background

This study aimed to assess the performance of transient elastography (TE), two-dimensional shear wave elastography (2D-SWE), and magnetic resonance elastography (MRE) for staging significant fibrosis and cirrhosis in untreated chronic hepatitis B (CHB) patients.

Methods

Pubmed, Embase, Web of Science, and Cochrane Library were searched for terms involving CHB, TE, 2D-SWE, and MRE. Other etiologies of chronic liver disease, previous treatment in patients, or articles not published in SCI journals were excluded. Hierarchical non-linear models were used to evaluate the diagnostic accuracy of TE, 2D-SWE, and MRE. Heterogeneity was explored via analysis of threshold effect and meta-regression.

Results

Twenty-eight articles with a total of 4,540 untreated CHB patients were included. The summary areas under the receiver-operating characteristic curves (AUROCs) using TE, 2D-SWE, and MRE for predicting significant fibrosis (SF) were 0.84, 0.89, and 0.99, respectively. The AUROC values of TE, 2D-SWE, and MRE for staging cirrhosis were 0.9, 0.94, and 0.99, respectively. Based on the meta-analysis of studies with head-to-head comparison, 2D-SWE is superior to TE (0.92 vs 0.85, P < 0.01) in staging significant fibrosis.

Conclusion

TE, 2D-SWE, and MRE express acceptable diagnostic accuracies in staging significant fibrosis and cirrhosis in untreated CHB patients. 2D-SWE outperforms TE in detecting significant fibrosis in treatment-naive people with hepatitis B virus.

The impact of the COVID-19 pandemic on adolescents and young adults living with type 2 diabetes

Objectives

The aim of this study was to assess the impacts of the COVID-19 pandemic on adolescents and young adults living with type 2 diabetes (T2D) involved in the national Improving Renal Complications in Adolescents with T2D through REsearch (iCARE) study.

Methods

The Environmental influences on Child Health Outcomes (ECHO) COVID-19 Questionnaire developed by the National Institutes of Health ECHO COVID-19 Task Force was administered to participants (n=85) from the iCARE study between June 2020 and October 2020. Children 12 years old (via parent report) and adolescents and young adults ≥13 years old (via self-report) participated. The questionnaire assessed the impact of the pandemic on health-care appointments, lifestyle, internet use, social connections and mental health.

Results

Participants were 17.0±3.1 (range, 12 to 27) years of age and predominantly female (61.3%). During the pandemic, 69.4% were able to attend their health-care appointments by telephone or virtual platforms, 31.7% ate more, 45.1% slept more and 29.3% spent less time on physical activities. There was an increase in internet use for both educational (42.0%) and noneducational purposes (54.9%). Participants felt less socially connected (64.6%). Participants also felt sometimes (59.2%), often (19.7%) and very often (6.7%) satisfied with their lives.

Discussion

Our study revealed that the COVID-19 pandemic has had various impacts on the daily lives of adolescents and young adults living with T2D. Future research should include longitudinal studies of the health burden of the COVID-19 pandemic on this population, with a more in-depth evaluation of mental health outcomes and clinical outcomes.

Transcriptional and Epigenetic Regulation of Monocyte and Macrophage Dysfunction by Chronic Alcohol Consumption

Drinking alcohol, even in moderation, can affect the immune system. Studies have shown disproportionate effects of alcohol on circulating and tissue-resident myeloid cells (granulocytes, monocytes, macrophages, dendritic cells). These cells orchestrate the body's first line of defense against microbial challenges as well as maintain tissue homeostasis and repair. Alcohol's effects on these cells are dependent on exposure pattern, with acute drinking dampening but chronic drinking enhancing production of inflammatory mediators. Although chronic drinking is associated with heightened systemic inflammation, studies on tissue resident macrophage populations in several organs including the spleen, liver, brain, and lung have also shown compromised functional and metabolic capacities of these cells. Many of these effects are thought to be mediated by oxidative stress caused by alcohol and its metabolites which can directly impact the cellular epigenetic landscapes. In addition, since myeloid cells are relatively short-lived in circulation and are under constant repopulation from the bone marrow compartment, alcohol's effects on bone marrow progenitors and hematopoiesis are important for understanding the impact of alcohol systemically on these myeloid populations. Alcohol-induced disruption of progenitor, circulating, and tissue resident myeloid populations contribute to the increased susceptibility of patients with alcohol use disorders to viral and bacterial infections. In this review, we provide an overview of the impact of chronic alcohol consumption on the function of monocytes and macrophages in host defense, tissue repair and inflammation. We then summarize our current understanding of the mechanisms underlying alcohol-induced disruption and examine changes in transcriptome and epigenome of monocytes and mcrophages. Overall, chronic alcohol consumption leads to hyper-inflammation concomitant with decreased microbial and wound healing responses by monocytes/macrophages due to a rewiring of the epigentic and transcriptional landscape. However, in advanced alcoholic liver disease, myeloid cells become immunosuppressed as a response to the surrounding hyper-inflammatory milieu. Therefore, the effect of chronic alcohol on the inflammatory response depends on disease state and the immune cell population.

A six years' experience with 41 cases of enterovesical fistula in a Tertiary National Hospital in Indonesia: A retrospective study

INTRODUCTION

The incidence of Enterovesical Fistula (EVF) is relatively low. Currently, there is no agreement about the best methods for EVF management. This study was performed to investigate the characteristics of EVF to find the optimal diagnostic and management pattern.

METHODS

Data were collected retrospectively from the medical record at Cipto Mangunkusumo Hospital. Patients diagnosed with EVF between January 2014 and April 2019 were included. They were evaluated for demographics, characteristics, diagnostic modalities, and treatment modalities.

RESULTS

From 41 patients, 26 (63.3%) are male, and 15 (36.6%) are female. Peak incidence was 51-60 years old. The most common symptoms are fecaluria found in 32 (78%) patients. The common etiology is gastrointestinal cancer found in 17 (41.5%) patients, followed by gynecologic cancer and diverticulitis found in both 9 (22%) patients. The rectovesical fistula was seen in 25 (61%) patients with an advanced stage rectosigmoid cancer, followed by colovesical in 14 (34.1%) of patients with sigmoid diverticulitis (p 0.038). The common diagnostic modalities performed are cystoscopy in 32 (78%), followed by colonoscopy in 11 (26.8%) patients. The preferred modalities that were used in most cases were surgery in 35 (85.4%) patients. A two-stage surgical approach was used in 28 (68.3%) patients.

CONCLUSION

The incidence of EVF is uncommon. Malignancy was the leading cause of EVF in this study. Combined diagnostic modalities are recommended in EVF cases. The two-stage surgical approach was the preferred modality. Further prospective studies are mandatory to analyze this condition.

Intracranial Osteoma: Unusual Etiology of Chronic Daily Headaches

Headache is one of the most frequent complaints in the outpatient department. The types of headaches can be broadly classified into primary and secondary. The primary headaches have benign intrinsic causes and include tension, migraine, and cluster headaches. A detailed history and appropriate physical examination are essential in assessing patients with headaches.  We present the case of a 33-year-old woman who presented to our primary care clinic with three days history of worsening frontal headache. She had been experiencing this headache daily for the last three months; however, the current episode is more severe. The headache episode was not associated with fever, neck stiffness, or loss of consciousness. She often became nauseated with the headache. There was no history of weakness, numbness, or visual disturbances with the headache. There was no family history of migraine headaches. On examination, no focal neurological deficit was noted. The head CT scan showed the presence of two highly hyperdense foci in the frontotemporal region, one of them was related to the dura. Such foci were not causing midline shift or brain edema. The preliminary diagnosis was calcified meningioma. Surgical excision of the lesions was planned. The patient underwent right craniotomy under general anesthesia. The two osseous lesions were observed and successfully resected. Histopathological examination of the lesions was consistent with osteoma. Intracranial osteoma is a very rare benign neoplasm of the mature bone tissue. The typical clinical manifestation of intracranial osteoma is a chronic headache. Head CT shows a well-defined, hyperdense structure. However, this is often mistaken as calcified meningioma.

Typical and Atypical Clinical Presentation of COVID-19 Infection in Children in The Top of Pandemic in EL-Minia Governorate (Two Center Experience)

BACKGROUND

A novel coronavirus that is identified as the cause of pandemic situation inFebruary2020 and affects adults and children with variable presentation and outcome.

OBJECTIVE

We studied the typical and atypical clinical and laboratory presentation of COVID-19 during the peak of the first wave in two main referral hospitals, upper Egypt EL-Minia governorate.

METHODS

Among 88 children with suspected cases tested for COVID-19, only 22 proved to be positive. Studied patients were classified into three groups based on age. The first group was 2-5years, the second was 5-10years, and the third included those aged more than 10 years. All patients met diagnostic guidelines established by the Egyptian Ministry of Health.

RESULTS

out of the positive 22 (25%) patients, 13(59.1%) of them were male, while 9 (40.9%) were females. All enrolled patients have a history of near contact exposure (100%). Thrombocytopenia was the highest presenting symptom in all enrolled patients18 (81.8%), while other hematological findings were anemia in 11 (50%), thrombotic symptoms in 2 (9.1%), pancytopenia in 2(9.1%) while bleeding was found in 1 patient (4.5%). Fever, present in 16 (72.7%), the most common constitutional symptom in COVID-19, was not reported in all enrolled patients, while sore throat was reported in only 2 patients (9.1%). The respiratory presentation was only dominant in positive chest C.T. finding, 17(72.3%), rather than clinical symptoms; GUT symptoms were the dominant presenting features as vomiting was found in 15 (68.2%), diarrhea in 10 (45.5%), abdominal pain in 11 (50%), jaundice in 9 (40.9%) and dehydration in 6 (27.3%). Neurological symptoms were convulsions in 4 (18.2%), while encephalopathy was 2 (9.1%). Nephritis was the only renal presentation in the enrolled patients, 3 (13.6%). Cardiac presentations were only cyanosis 8 (36.4%) and arrhythmias 6 (27.3%).

CONCLUSION

COVID-19 has many clinical classic presentations in children; however other non-typical presentations like hematological, CNS, and renal presentations have been reported.

Clinical Characteristics and Pathogenic Gene Identification in Chinese Patients With Paget's Disease of Bone

OBJECTIVE

To evaluate the clinical features of sporadic Paget's disease of bone (PDB) in China and further explore the underlying genetic abnormalities of the disease.

METHODS

Clinical characteristics, biochemical indices, bone turnover markers and radiographic examinations of the patients were collected. Genomic DNA was extracted from peripheral blood and whole-exome sequencing was carried out to identify the potential pathogenic genes. The pathogenicity of the variants was thereafter investigated by bioinformatics analysis.

RESULTS

A total of 50 patients (57.20 ± 15.52 years, male/female: 1.63: 1) with PDB were included and the mean onset age was 48.34 years (48.34 ± 17.24 years). 94.0% of the patients exhibited symptomatic patterns described as bone pain (86.0%), elevated skin temperature at the lesion site (26.0%), bone deformity (22.0%) and local swelling (18.0%). The most frequently involved lesion sites were pelvis (52.0%), femur (42.0%), tibia (28.0%), skull (28.0%) and spine (18.0%), respectively. Additionally, 40.0% of them accompanied with osteoarthritis, 14.0% with pathological fractures, and the misdiagnosis rate of PDB was as high as 36.0%. Serum level of alkaline phosphatase was significantly increased, with the mean value of 284.00 U/L (quartiles, 177.00-595.00 U/L). Two heterozygous missense mutations of SQSTM1 gene (c.1211T>C, M404T) and one novel heterozygous missense mutation in HNRNPA2B1 gene (c.989C>T, p. P330L) were identified in our study. Moreover, several potential disease-causing genes were detected and markedly enriched in the pathways of neurodegeneration (including WNT16, RYR3 and RYR1 genes) and amyotrophic lateral sclerosis (ALS, including NUP205, CAPN2, and NUP214 genes).

CONCLUSION

In contrast to Western patients, Chinese patients have an earlier onset age, more severe symptoms, and lower frequency of SQSTM1 gene mutation (4.0%). Moreover, a novel heterozygous missense mutation in HNRNPA2B1 gene was identified in one male patient with isolated bone phenotype. As for other genetic factors, it was indicated that WNT16, RYR3, RYR1, NUP205, CAPN2 and NUP214 genes may be potential pathogenic genes, pathways of neurodegeneration and ALS may play a vital role in the pathogenesis of PDB.

Understanding How Sensory Changes Experienced by Individuals with a Range of Age-Related Cognitive Changes Can Effect Technology Use

Clinical researchers have identified sensory changes people with age-related cognitive changes, such as dementia and mild cognitive impairment, experience that are different from typical age-related sensory changes. Technology designers and researchers do not yet have an understanding of how these unique sensory changes affect technology use. This work begins to bridge the gap between the clinical knowledge of sensory changes and technology research and design through interviews with people with mild to moderate dementia, mild cognitive impairment, subjective cognitive decline, and healthcare professionals. This extended version of our ASSETS conference paper includes people with a range of age-related cognitive changes describing changes in vision, hearing, speech, dexterity, proprioception, and smell. We discuss each of these sensory changes and ways to leverage optimal modes of sensory interaction for accessible technology use with existing and emerging technologies. Finally, we discuss how accessible sensory stimulation may change across the spectrum of age-related cognitive changes.

Dysphagia in lateral medullary syndrome

Introduction. The lateral medullary syndrome is a neurological disease caused by ischemia in the lateral part of the medulla oblongata and is the most common form of brainstem infarction. Dysphagia is a common and clinically significant symptom of this disease because it is closely associated with the risk of recurrent pneumonia, malnutrition, dehydration, and an increase in mortality and prolonged hospital treatment. Aim. This paper aims to review and analyze data on the correlation between swallowing disorders and lateral medullary syndrome. We intend to present the symptoms, diagnostic and therapeutic procedures of dysphagia in patients with this syndrome in a comprehensive way. Methodology. The following databases were used to search the literature: KoBSON-Consortium of Serbian Libraries for Unified Procurement, PubMed, Science Direct. Results. Based on the results of the reviewed studies, it was determined that patients with the lateral medullary syndrome often have swallowing disorders. They are often fed through a nasogastric tube a few months after the stroke, which significantly impairs their quality of life. To overcome swallowing disorders and create conditions for safe swallowing function, most patients need treatment for a longer period. In addition to the available screening tests, instrumental diagnostic methods provide insight into the biomechanical aspects of swallowing disorders, determine the risk of aspiration, and provide a starting point for selecting treatment strategies. Conclusion. Treatment of dysphagia depends on the mechanisms of occurrence and the predictors of recovery of swallowing function. When conducting treatment, among other things, it is very important to know the pathological mechanisms of neural connections of the medulla oblongata.

Infected aortic pseudoaneurysm caused by an inferior vena cava filter

Background

Inferior vena cava filters are widely used to prevent pulmonary embolism, but they can cause serious complications.

Case Presentation

A 45‐year‐old man with multiple abscesses was transferred to the emergency department from another hospital. Computed tomography revealed bilateral subscapular abscesses, septic pulmonary embolism, and an abdominal aortic pseudoaneurysm with an abscess at the site of the inferior vena cava filter limb inserted 12 years before. After admission to our hospital, surgical drainage of the bilateral subscapular and right wrist joint abscesses was performed; subsequent treatment with ampicillin improved the patient's condition. Inflammation resolved on the 19th hospitalization day, and abdominal aortic replacement surgery was performed. The patient's postoperative course was uneventful. He returned to the previous hospital for rehabilitation after 40 days of hospitalization.

Conclusion

Inferior vena cava filters could cause serious complications.

Electrocardiographic Changes During Initiation of Lithium Augmentation of Antidepressant Pharmacotherapy

PURPOSE/BACKGROUND

Lithium augmentation of antidepressants represents a common strategy to overcome treatment resistance in patients with major depressive disorder. The use of lithium has been associated with cardiovascular adverse effects such as QTc prolongation and tachyarrhythmia. Although the previous studies investigated monotherapy with lithium, the aim of this study was to investigate electrocardiographic changes in LA.

METHODS/PROCEDURES

A 12-lead surface electrocardiogram (ECG) was obtained from 38 patients with major depressive disorder before and during LA. Changes in heart rate, PQ, QRS and QTc interval, QT dispersion, ST segment, and T- and U-wave alterations were analyzed using a linear mixed model.

FINDINGS/RESULTS

The ECG readings of 33 patients were evaluated. Lithium augmentation was not significantly associated with changes in heart rate, QTc, PQ, or QRS interval. We found a significant decrease in QT dispersion. These results were independent of sex, age, stable comedication, and comorbidities. During LA, we observed 9 cases of T-wave alterations and 2 cases of new U waves.

CONCLUSIONS

Our data provide no evidence for serious ECG abnormalities at therapeutic serum lithium levels in patients treated with LA. In particular, we did not find evidence for QTc time lengthening or tachyarrhythmia, such as torsades des pointes. The recommended intervals for ECG checks should be considered to detect long-term effects of LA.

GPR, King's Score and S-Index are superior to other non-invasive fibrosis markers in predicting the liver fibrosis in chronic Hepatitis B patients

Background and study aims

In this study, we investigated the efficacy of nine non-invasive fibrosis markers in the assessment of the degree of fibrosis in patients with chronic Hepatitis B (CHB) in comparison with liver biopsy.

Patients and methods

A total of 1454 untreated CHB patients from two different centers who underwent liver biopsy were included in the study. Laboratory results of patients were reviewed retrospectively and the pathology slides were re-evaluated in accordance with the Ishak score. Degree of fibrosis ≥ 3 was accepted as "significant fibrosis", ≥ 4 as "advanced fibrosis", and ≥ 5 as cirrhosis. The diagnostic performance of the markers Aspartate aminotransferase to Platelet Ratio Index (APRI), Fibrosis-4 score (FIB-4), Aspartate aminotransferase to Alanine aminotransferase Ratio (AAR), AAR to Platelet Ratio Index (AAPRI), Gamma-glutamyl transpeptidase to Platelet Ratio (GPR), King's Score, Fibro quotient (Fibro-Q), S Index and Platelet to Lymphocyte Ratio (PLR) were evaluated with ROC analysis.

Results

In detecting significant fibrosis, APRI, GPR, King's Score and S Index had AUROC values over 0.70. For advanced fibrosis, all of the models except AAPRI; and for cirrhosis, all of the models had AUROC values over 0.70. In accordance with the chosen staging system, GPR, King's Score and S Index had high diagnostic efficacy whereas APRI, FIB-4, FibroQ and PLR had moderate diagnostic efficacy, AAR and AAPRI had low diagnostic efficacy.

Conclusions

GPR, King's Score and S Index had moderate diagnostic performance in detecting significant fibrosis and advanced fibrosis, and high diagnostic performance in detecting cirrhosis.

WAYS TO IMPROVE THE RESULTS OF SURGICAL TREATMENT OF PATIENTS WITH ATYPICAL FORMS OF ACUTE APPENDICITIS

OBJECTIVE

The aim: To search for new and improvement of known methods of diagnosis and surgical treatment of atypical forms of acute appendicitis.

PATIENTS AND METHODS

Materials and methods: There were analyzed the results of diagnosis and surgical treatment of 852 patients with atypical course of acute appendicitis, which amounted to 25.3% of the total number of patients in this category. Depending on the chosen diagnostic and treatment tactics, patients with acute atypical appendicitis were divided into two groups: control (n=423) and main (n=429).

RESULTS

Results: It was found that among atypical forms of acute appendicitis retrocecal location of the appendix is 61.2% of cases, pelvic - 24.3%, medial - 11.2%, subhepatic - 3.4%. Destructive forms of atypical acute appendicitis occurred in a total of 92.5% of cases, 77.7% of patients had various types of peritonitis.

CONCLUSION

Conclusions: Authors improved and tested a number of diagnostic (rectal thermometry, ethanol test) and operative methods for destructive forms of acute appendicitis complicated by typhoid (including laparoscopic). The proposed diagnostic and treatment algorithm allowed to optimize the treatment tactics of this category of patients and reduce the incidence of complications in the early postoperative period from 9.9% to 3.5% (p<0.001).

Plasma oxalic acid and cardiovascular risk in end-stage renal disease patients: a prospective, observational cohort pilot study

BACKGROUND/AIMS

It was hypothesized that oxalate might be strongly involved in atherogenesis and the inflammatory pathway that could result in an increased risk of cardiovascular disease (CVD) in end-stage renal disease (ESRD) patients. Therefore, this study aimed to address two primary research questions: to characterize the lipid profile and the pattern of pro-inflammatory cytokines according to plasma oxalic acid (POx) concentration in ESRD patients; to evaluate the potential role of elevated POx concentration in the development of CVD risk.

METHODS

A total of 73 participants were enrolled in this prospective, observational cohort pilot study. Among them, there were 50 ESRD patients and 23 healthy volunteers. The lipid profile and the pro-inflammatory cytokines were analyzed according to the distribution of POx concentration into tertiles. After the clinical examination, 29 hemodialysis patients and 21 peritoneal dialysis patients without prevalent CVD were observed for CVD events for 2 years. The Cox regression analysis and a set of different types of sensitivity analyses were used to determine whether elevated POx was associated with an increased risk of CVD.

RESULTS

An increasing trend in the atherogenic lipoprotein fractions and the pro-inflammatory markers as well as a linear decrease in high-density lipoprotein was significantly associated with elevated POx. POx concentration ≥ 62.9 μmol/L was significantly associated with CVD events independently of other examined CVD risk factors.

CONCLUSION

This pilot study firstly demonstrated a potential contribution of POx to atherogenesis, inflammation and CVD risk in ESRD patients.

Circulating microRNA associated with future relapse status in major depressive disorder

Major depressive disorder (MDD) is an episodic condition with relapsing and remitting disease course. Elucidating biomarkers that can predict future relapse in individuals responding to an antidepressant treatment holds the potential to identify those patients who are prone to illness recurrence. The current study explored relationships between relapse risk in recurrent MDD and circulating microRNAs (miRNAs) that participate in RNA silencing and post-transcriptional regulation of gene expression. Serum samples were acquired from individuals with a history of recurrent MDD who were followed longitudinally in the observational study, OBSERVEMDD0001 (ClinicalTrials.gov Identifier: NCT02489305). Circulating miRNA data were obtained in 63 participants who relapsed ("relapsers") and 154 participants who did not relapse ("non-relapsers") during follow-up. The miRNA was quantified using the ID3EAL™ miRNA Discovery Platform from MiRXES measuring 575 circulating miRNAs using a patented qPCR technology and normalized with a standard curve from spike-in controls in each plate. The association between miRNAs and subsequent relapse was tested using a linear model, adjusting for age, gender, and plate. Four miRNAs were nominally associated with relapse status during the observational follow-up phase with a false discover rate adjusted p-value < 0.1. Enrichment analysis of experimentally validated targets revealed 112 significantly enriched pathways, including neurogenesis, response to cytokine, neurotrophin signaling, vascular endothelial growth factor signaling, relaxin signaling, and cellular senescence pathways. These data suggest these miRNAs putatively associated with relapse status may have the potential to regulate genes involved in multiple signaling pathways that have previously been associated with MDD. If shown to be significant in a larger, independent sample, these data may hold potential for developing a miRNA signature to identify patients likely to relapse, allowing for earlier intervention.

Complication after the reconstruction of the old patellar tendon rupture

Introduction. Chronic patellar tendon rupture (PTR) occurs rarely; its frequency and prevalence are unknown. There are very little data on the late patellar tendon reconstruction in rheumatoid arthritis and its complications. Case report. We presented a surgical repair of a PTR with early postoperative rupture of the contralateral patellar tendon for a 21-year-old woman with a past medical history of juvenile rheumatoid arthritis (treated with corticosteroids) who sustained initial injury 11 months prior to the presentation. The contralateral side was used for autograft harvesting. We used bone-tendon-bone (BTB) autograft and allografts followed by double-wire loop reinforcement and immediate postoperative mobilization. The patient was followed for 2 years, and the function of both knees was re-stored completely, with a full active range of motion. In this case, reconstruction of an 11-month-old chronic PTR (with complete resorption of the tendon and completely separated infrapatellar pads, complicated by the contralateral PTR) with BTB autograft and allografts and double wire loop reinforcement gave an excellent functional result. Two years after the surgical treatment, the extensor function of both knees was completely restored with a full range of movements. The patient reported satisfying outcomes and was able to return to all pre-injury activities without the assistance of orthopedic devices. Conclusion. This case report highlights the importance of the early diagnosis and describes operative techniques used in chronic PTR repair and treatments of the early postoperative complications such as rupture of the contralateral tendon.

Increased Demand for Therapeutic Drugs in Pediatric Ulcerative Colitis Patients With Extraintestinal Manifestations

BACKGROUND

Ulcerative colitis (UC) is a systemic inflammatory disease with a gut predominance, which may involve other organs. The presence of extraintestinal manifestation (EIM) is an important symptom for clinicians as it alters the treatment decisions. In this study, we aimed to evaluate the initial clinical presentation and disease severity of pediatric UC patients with EIMs.

METHODS

One hundred forty-two patients under the age of 18 years who were diagnosed with UC from January 2003 to November 2021 were included in this study. Forty-seven patients with confirmed EIMs and 95 patients without EIMs were divided into two groups and their differences were analyzed.

RESULTS

The most common EIM was peripheral arthritis. The disease extent at the time of diagnosis shows a higher rate of pancolitis in the EIM-positive group (65.9%) than that of the EIM-negative group (33.7%) (p < 0.001). More than 90% of EIM-positive patients had moderate to severe disease activity on the Mayo endoscopic subscore. In the EIM-positive group, the cumulative use of systemic steroids, immunosuppressants, and biological agents from diagnosis to 1 year follow-up were significantly higher than those of the EIM-negative group (p = 0.009, 0.001, and < 0.001, respectively). About 80% of patients in the EIM-negative group reached remission, but only about 50% of the EIM-positive patients reached remission (p = 0.005). The relapse occurred more frequently in the EIM-positive group than in the EIM-negative group with statistical significance (p < 0.001).

CONCLUSION

Pediatric UC with EIMs had higher disease severity and often manifested upper gastrointestinal tract involvement. Despite EIMs treatment, the occurrence of new EIMs was observed repeatedly. Cumulative drug demand (steroids, immunosuppressants, and biological agents) for the treatment increased steadily over time, and frequent relapses occurred despite the combinatory use of therapeutic drugs.

Risk Factors for Bacteremia After Endoscopic Procedures in Hospitalized Patients With a Focus on Neutropenia

BACKGROUND

The risk for bacteremia following endoscopic procedures varies among studies. A low neutrophil count is considered as a risk factor.

OBJECTIVE

To assess risk factors for bacteremia following endoscopic procedures, focusing on neutropenia.

METHODS

This was a retrospective analysis of all inpatients undergoing endoscopic procedures between 2005 and 2018 with neutrophil count taken within 72 hours before the procedure in a tertiary center in Israel. The primary outcome was positive blood culture within 48 hours following the procedure of bacteria that was not cultured before. Risk factors for bacteremia were assessed and multivariate logistic regression models were built. In neutropenic patients, comparator groups were used to assess the risk related to the procedure and neutropenia.

RESULTS

Of 13,168 patients included, postprocedural bacteremia was recorded in 103 (0.8%). Neutropenia, low albumin level, male gender, older age, preprocedure fever, and admitting department were associated with increased risk for bacteremia in both univariate and multivariate analyses. A multivariate model including these factors was found to be predictive of bacteremia (area under the curve 0.82; 95% confidence interval, 0.78-0.88). In neutropenic patients, the risk of postendoscopic bacteremia (4.2%) was not significantly different compared with neutropenic patients undergoing bronchoscopy (1.8%, P=0.14) or from the rate of bacteremia-to-neutropenic episodes ("background risk") in neutropenic patients in general (6.3%, P=0.33).

CONCLUSIONS

Postendoscopic bacteremia is a rare event among inpatients. Although neutropenia was found to be a risk factor for bacteremia, it was not higher than the background risk in these patients. Models highly predictive of bacteremia were developed and should be validated.

Effects of Dexmedetomidine on Diaphragm Activity Measured by Ultrasonography in Spontaneously Breathing Patients

Background: Diaphragm movement is well correlated with inspired volume of the lung. Dexmedetomidine (DEX) has less effect on respiratory functions than other sedatives. The objective of this study was to investigate diaphragmatic movement using ultrasound (US) during DEX infusion for sedation in spontaneously breathing patients undergoing unilateral upper limb surgery. Methods: A total of 33 consecutive patients were enrolled in this study. Patients were sedated using DEX with ipsilateral axillary brachial nerve plexus block. Diaphragmatic activity was evaluated using diaphragmatic thickening at end-inspiration (TEI), diaphragmatic thickening at end-expiration (TEE), and diaphragmatic thickening fraction (DTF) measured by diaphragmatic US at three time-points; T0, baseline; T1, after DEX sedation; and T2, after DEX recovery. Supplementary oxygen was applied with a simple mask at 5 L/min. Peripheral oxygen saturation (SpO₂), end tidal CO₂ (EtCO₂), and respiratory rate (RR) were recorded. Results: TEI and TEE showed no significant changes during the study period (P = 0.394 and P = 0.205, respectively). DTF was maintained at both T0 and T1 (P = 1.000). At recovery after DEX infusion discontinued, DTF was increased by 3.85%, although such increase was not statistically significant (T0 vs. T2, P = 0.525). SpO₂ remained above 99% and EtCO₂ remained below 36 mmHg. Desaturation episodes were not observed during the study period. Conclusions: Results of this study showed that DEX sedation did not affect the diaphragmatic movement in situation of decreased RR induced by DEX. This finding implies that DEX-induced sedation does not result in clinically significant respiratory depression.

Risk factors for fluctuations in corneal endothelial cell density (Review)

The cornea is a transparent, avascular and abundantly innervated tissue through which light rays are transmitted to the retina. The innermost layer of the cornea, also known as the endothelium, consists of a single layer of polygonal endothelial cells that serve an important role in preserving corneal transparency and hydration. The average corneal endothelial cell density (ECD) is the highest at birth (~3,000 cells/mm²), which then decrease to ~2,500 cells/mm² at adulthood. These endothelial cells have limited regenerative potential and the minimum (critical) ECD required to maintain the pumping function of the endothelium is 400-500 cells/mm². ECD < the critical value can result in decreased corneal transparency, development of corneal edema and reduced visual acuity. The condition of the corneal endothelium can be influenced by a number of factors, including systemic diseases, such as diabetes or atherosclerosis, eye diseases, such as uveitis or dry eye disease (DED) and therapeutic ophthalmological interventions. The aim of the present article is to review the impact of the most common systemic disorders (pseudoexfoliation syndrome, diabetes mellitus, cardiovascular disease), eye diseases (DED, uveitis, glaucoma, intraocular lens dislocation) and widely performed ophthalmic interventions (cataract surgery, intraocular pressure-lowering surgeries) on corneal ECD.

Comparison of Ocular Morphological Parameters Related to Lens Position by Anterior Segment Optical Coherence Tomography and Ultrasound Biomicroscopy

OBJECTIVE

The objective is to compare parameters related to lens position measured using anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) in patients with senile cataract and perform a consistency analysis.

METHODS

This prospective study included 102 patients (102 eyes) scheduled for simple cataract surgery. Among the total patients, 44 were men, and 58 were women. AS-OCT (sitting) and UBM (lying) were used to measure the anterior chamber depth (ACD) in horizontal and vertical orientations and the iris-lens contact distance (ILCD) and iris-lens angle (ILA) in inferior, superior, nasal, and temporal quadrants. Paired-sample t-test was used to compare ACD, ILCD, and ILA measurements of the two methods, while Pearson's linear correlation and Bland-Altman analyses were used to analyze the correlation and consistency of the two results.

RESULTS

The horizontal (2.499 ± 0.464 mm) and vertical (2.531 ± 0.463 mm) ACD measured using AS-OCT and the horizontal (2.556 ± 0.467 mm) and vertical (2.563 ± 0.479 mm) ACD measured using UBM were significantly different (P < 0.001); moreover, the results showed good correlation and agreement. A significant difference was observed between the two methods in terms of ILCD measured in inferior, superior, nasal, and temporal quadrants (P < 0.001), and a significant correlation was found between measurements of both methods (P < 0.001). Approximately 3.92% (4/102), 0.98% (1/102), 3.92% (4/102), and 2.94% (3/102) of points were outside the 95% limits of agreement in the four quadrants, respectively, and the agreement of the results was good. ILA measured using both methods differed in inferior, superior, nasal, and temporal quadrants (P=0.003, 0.011, 0.001, 0.001, respectively), and the correlation was good (P < 0.001). The percentage of points outside the 95% limit was higher in inferior, superior, nasal, and temporal quadrants (4.90% (5/102), 5.88% (6/102), 5.88% (6/102), and 6.86% (7/102)) with poor agreement of the results.

CONCLUSIONS

The correlation between AS-OCT and UBM in terms of measuring lens position-related parameters was good, but the agreement was unstable. The differences in measurement position (sitting and supine) and/or measurement methods (optics and ultrasound) may lead to variability in results.

Targeted management of evolving and established chronic lung disease of prematurity assisted by cardiopulmonary ultrasound: A case report of four patients

Bronchopulmonary dysplasia (BPD) is one of the most common complications of premature birth. The current definition of BPD is based on the duration of oxygen therapy and/or respiratory support. Among the pitfalls of all the diagnostic definitions, the lack of a proper pathophysiologic classification makes it difficult to choose an appropriate drug strategy for BPD. In this case report, we describe the clinical course of four premature infants, admitted to the neonatal intensive care unit, for whom the use of lung and cardiac ultrasound was an integral part of the diagnostic and therapeutic process. We describe, for the first time to our knowledge, four different cardiopulmonary ultrasound patterns of evolving and established chronic lung disease of prematurity and the consequent therapeutic choices. This approach, if confirmed in prospective studies, may guide the personalized management of infants suffering from evolving and established BPD, optimizing the chances of success of the therapies and at the same time reducing the risk of exposure to inadequate and potentially harmful drugs.

Microcystin-LR incorporated into colonic cells through probenecid-sensitive transporters leads to upregulated MCP-1 expression induced by JNK activation

Harmful algae that inhabit eutrophic lakes produce cyanotoxic microcystins. Therefore, the relationship between chronic exposure to microcystins via drinking water and organ disorders has been investigated. The present study aimed to determine whether representative microcystin-LR is involved in increased monocyte chemoattractant protein-1 (MCP-1) expression in rat colonic mucosa and enterocyte-like differentiated Caco-2 cells. The mRNA expression of MCP-1 was increased in the colons of rats administered with microcystin-LR, compared with controls. Furthermore, mRNA levels of MCP-1 expression significantly and positively correlated with those of Adhesion G Protein-Coupled Receptor E1 (ADGRE1; EMR1; F4/80), an indicator of macrophage infiltration, suggesting that increased MCP-1 expression induced by microcystin-LR promotes macrophage infiltration into the colon. Microcystin-LR increased MCP-1 expression in enterocyte-like differentiated Caco-2 cells, by activating c-Jun N-terminal kinase (JNK), but not extracellular signal-regulated kinase (ERK) or p38. The findings of transporter inhibitors indicated that microcystin-LR is incorporated into cells via ATP Binding Cassette (ABC) or solute carrier (SLC) transporters other than the organic anion transporting polypeptides (OATPs)1B1, 1B3, 2B1, and 1A2, which this leads to increased MCP-1 expression in the colon through activating JNK. Thus, increased MCP-1 expression induced by microcystin-LR might be a trigger for initiating tumorigenesis with inflammation in the colon because increased MCP-1 expression induces inflammation associated with macrophage infiltration into the colon, and chronic inflammation is associated with the initiation of tumorigenesis.

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Microcystin-LR upregulated colonic MCP-1 expression in rats.

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Increased MCP-1 expression correlated with accumulated macrophages in rat colon.

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Microcystin-LR evoked MCP-1 expression by activating JNK in cultured colon cells.

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Rifampicin was not involved in microcystin-LR-induced JNK activation.

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Probenecid suppressed JNK/MCP-1 pathway activation induced by microcystin-LR.

Dietary influence on modulation of Helicoverpa armigera oral secretion composition leading to differential regulation of tomato plant defense

Little is known about how different plant-based diets influence the insect herbivores' oral secretion (OS) composition and eventually the plant defense responses. We analyzed the OS composition of the generalist Lepidopteran insect, Helicoverpa armigera feeding on the host plant tomato (OS_H), non-host plant capsicum (OS_NH), and artificial diet (OS_AD) using Liquid Chromatography-Quadrupole Time of Flight Mass Spectrometry. Higher numbers and levels of alkaloids and terpenoids were observed in OS_H and OS_NH, respectively while OS_AD was rich in phospholipids. Interestingly, treatment of H. armigera OS_AD, OS_H and OS_NH on wounded tomato leaves showed differential expression of (i) genes involved in JA and SA biosynthesis and their responsive genes, and (ii) biosynthetic pathway genes of chlorogenic acid (CGA) and trehalose, which exhibited increased accumulation along with several other plant defensive metabolites. Specifically, high levels of CGA were detected after OS_H and OS_NH treatments in tomato leaves. There was higher expression of the genes involved in phenylpropanoid biosynthesis, which may lead to the increased accumulation of CGA and related metabolites. In the insect bioassay, CGA significantly inhibited H. armigera larval growth. Our results underline the differential accumulation of plant and insect OS metabolites and identified potential plant metabolite(s) affecting insect growth and development.

Hepatitis C Screening Among Medicaid Patients With Schizophrenia, 2002-2012

OBJECTIVE

Although people with schizophrenia are disproportionately affected by Hepatitis C virus (HCV) compared to the general population, HCV screening among US Medicaid recipients with schizophrenia has not been characterized. Following 1998 CDC recommendations for screening in high-risk populations, we estimated the proportion of Medicaid recipients with and without schizophrenia screened for HCV across states and over time. Examining patterns of screening will inform the current public health imperative to test all adults for HCV now that safer and more effective treatments are available.

METHODS

Data are drawn from 1 353 424 Medicaid recipients aged 15-64 years with schizophrenia and frequency-matched controls from 2002 to 2012. Participants with known HCV infection one year prior and those dual-eligible for Medicare were excluded. Multivariable logistic regression estimated associations between predictor variables and HCV screening.

RESULTS

HCV screening was low (<4%) but increased over time. Individuals with schizophrenia consistently showed higher screening compared to controls across years and states. Several demographic and clinical characteristics predicted higher screening, especially comorbid HIV (OR = 6.5; 95% CI = 6.0-7.0). Outpatient medical care utilization increased screening by nearly double in 2002 (OR = 1.8; CI = 1.7-1.9) and almost triple in 2012 (OR = 2.7; CI = 2.6-2.9).

CONCLUSIONS

Low screening was a missed opportunity to improve HCV prevention efforts and reduce liver-related mortality among people with schizophrenia. Greater COVID-19 disease severity in HCV patients and the availability of effective HCV treatments increase the urgency to improve HCV screening. Eliminating Medicaid restrictions and expanding statewide HIV policies to include HCV would have multiple public health benefits, particularly for people with schizophrenia.

Impact of COVID-19 and other infectious conditions requiring isolation on the provision of and adaptations to fundamental nursing care in hospital in terms of overall patient experience, care quality, functional ability, and treatment outcomes: systematic review

AIM

This systematic review identifies, appraises and synthesizes the evidence on the provision of fundamental nursing care to hospitalized patients with a highly infectious virus and the effectiveness of adaptations to overcome barriers to care.

DESIGN

Systematic review.

DATA SOURCES

In July 2020, we searched Medline, PsycINFO (OvidSP), CINAHL (EBSCOhost), BNI (ProQuest), WHO COVID-19 Database (https://search.bvsalud.org/) MedRxiv (https://www.medrxiv.org/), bioRxiv (https://www.biorxiv.org/) and also Google Scholar, TRIP database and NICE Evidence, forwards citation searching and reference checking of included papers, from 2016 onwards.

REVIEW METHODS

We included quantitative and qualitative research reporting (i) the views, perceptions and experiences of patients who have received fundamental nursing care whilst in hospital with COVID-19, MERS, SARS, H1N1 or EVD or (ii) the views, perceptions and experiences of professional nurses and non-professionally registered care workers who have provided that care. We included review articles, commentaries, protocols and guidance documents. One reviewer performed data extraction and quality appraisal and was checked by another person.

RESULTS

Of 3086 references, we included 64 articles; 19 empirical research and 45 review articles, commentaries, protocols and guidance documents spanning five pandemics. Four main themes (and 11 sub-themes) were identified. Barriers to delivering fundamental care were wearing personal protective equipment, adequate staffing, infection control procedures and emotional challenges of care. These barriers were addressed by multiple adaptations to communication, organization of care, staff support and leadership.

CONCLUSION

To prepare for continuation of the COVID-19 pandemic and future pandemics, evaluative studies of adaptations to fundamental healthcare delivery must be prioritized to enable evidence-based care to be provided in future.

IMPACT

Our review identifies the barriers nurses experience in providing fundamental care during a pandemic, highlights potential adaptations that address barriers and ensure positive healthcare experiences and draws attention to the need for evaluative research on fundamental care practices during pandemics.

Content-based image retrieval with a Convolutional Siamese Neural Network: Distinguishing lung cancer and tuberculosis in CT images

BACKGROUND

CT findings of lung cancer and tuberculosis are sometimes similar, potentially leading to misdiagnosis. This study aims to combine deep learning and content-based image retrieval (CBIR) to distinguish lung cancer (LC) from nodular/mass atypical tuberculosis (NMTB) in CT images.

METHODS

This study proposes CBIR with a convolutional Siamese neural network (CBIR-CSNN). First, the lesion patches are cropped out to compose LC and NMTB datasets and the pairs of two arbitrary patches form a patch-pair dataset. Second, this patch-pair dataset is utilized to train a CSNN. Third, a test patch is treated as a query. The distance between this query and 20 patches in both datasets is calculated using the trained CSNN. The patches closest to the query are used to give the final prediction by majority voting. One dataset of 719 patients is used to train and test the CBIR-CSNN. Another external dataset with 30 patients is employed to verify CBIR-CSNN.

RESULTS

The CBIR-CSNN achieves excellent performance at the patch level with an mAP (Mean Average Precision) of 0.953, an accuracy of 0.947, and an area under the curve (AUC) of 0.970. At the patient level, the CBIR-CSNN correctly predicted all labels. In the external dataset, the CBIR-CSNN has an accuracy of 0.802 and AUC of 0.858 at the patch level, and 0.833 and 0.902 at the patient level.

CONCLUSIONS

This CBIR-CSNN can accurately and automatically distinguish LC from NMTB using CT images. CBIR-CSNN has excellent representation capability, compatibility with few-shot learning, and visual explainability.

Managing Antiphospholipid Syndrome in Children and Adolescents: Current and Future Prospects

Pediatric antiphospholipid syndrome (APS) is a rare acquired multisystem autoimmune thromboinflammatory condition characterized by thrombotic and non-thrombotic clinical manifestations. APS in children and adolescents typically presents with large-vessel thrombosis, thrombotic microangiopathy, and, rarely, obstetric morbidity. Non-thrombotic clinical manifestations are frequently seen in pediatric APS and may be present even before the vascular thrombotic events occur. We review insights into the pathogenesis of APS and discuss potential targets for therapy. The identification of multiple immunologic abnormalities in patients with APS reveals molecular targets for current or future treatment. Management strategies, especially for APS in adolescents, require screening for additional prothrombotic risk factors and consideration of counseling regarding contraceptive strategies, lifestyle recommendations, treatment adherence, and mental health issues associated with this autoimmune thrombophilia. The main goal of therapy in pediatric APS is the prevention of thrombosis. The management of acute thrombosis events in children and adolescents is the same as for primary APS, which involves isolated occurrences, and secondary APS, which is seen in association with another autoimmune disease, e.g., systemic lupus erythematosus. A pediatric hematologist should be consulted so other differential thrombophilic conditions can be eliminated. Therapy includes unfractionated heparin or low-molecular-weight heparin followed by vitamin K antagonists. Treatment of catastrophic APS involves triple therapy (anticoagulation, intravenous corticosteroid pulse therapy, and plasma exchange) and may include intravenous immunoglobulin for children and adolescents with this condition. New drugs such as eculizumab and sirolimus seem to be promising drugs for APS.

Acanthosis Nigricans: An Updated Review

BACKGROUND

Early recognition of acanthosis nigricans is important because acanthosis nigricans can be a cutaneous manifestation of a variety of systemic disorders and, rarely, as a sign of internal malignancy.

OBJECTIVE

The purpose of this article is to familiarize pediatricians with the clinical manifestations, evaluation, diagnosis, and management of acanthosis nigricans.

METHODS

A search was conducted in November 2021in PubMed Clinical Queries using the key term "acanthosis nigricans". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Acanthosis nigricans is characterized by symmetric, hyperpigmented, and velvety plaques with ill-defined borders, typically involving intertriginous areas. Obesity is the most common cause of acanthosis nigricans which is increasingly observed in obese children and adolescents and can serve as a cutaneous marker of insulin resistance. Early recognition of acanthosis nigricans is important because acanthosis nigricans can also be a cutaneous manifestation of a variety of systemic disorders and, rarely, as a sign of internal malignancy. This may consist of weight reduction, discontinuation of causative drugs, treatment of underlying endocrinopathy, or treatment of an underlying malignancy. For patients with isolated acanthosis nigricans and for those whose underlying cause is not amenable to treatment, treatment of the lesion may be considered for cosmetic reasons. Topical retinoids, vitamin D analogs, chemical peels, and other keratolytics are often used for the treatment of localized lesions. Seldom, systemic therapy such as oral retinoids may be considered for extensive or generalized acanthosis nigricans and acanthosis nigricans unresponsive to topical therapy. Other uncommon treatment modalities include dermabrasion, laser therapy, and surgical removal.

CONCLUSION

Although acanthosis nigricans is treatable, a complete cure is difficult to achieve. The underlying cause should be treated, if possible, to resolve and prevent the recurrence of acanthosis nigricans. The diagnosis is mainly clinical, based on the characteristic appearance (symmetrically distributed, hyperpigmented, velvety, papillomatous, hyperkeratotic plaques with ill-defined borders) and the typical sites (intertriginous areas, flexural area, and skin folds) of the lesions. The diagnosis might be difficult for lesions that have atypical morphology or are in an unusual location. Clinicians should be familiar with the clinical signs, evaluation, diagnosis, and therapy of acanthosis nigricans because of the link between it and underlying diseases.

Clinical characteristics of older Japanese patients with acute appendicitis: A post hoc analysis

BACKGROUND

Acute appendicitis (AA) in older patients can look different from AA in younger patients. Although it is crucial that primary care physicians can recognize AA in patients of any age, few Japanese studies have examined the characteristics of older AA patients. To address this, we evaluated the clinical characteristics of older Japanese patients with AA.

METHODS

We performed a post hoc analysis of the data from a previous Japanese single-center study. We analyzed the clinical information of both younger (age: 16-64 years) and older patients (age: ≥65 years).

RESULTS

A cohort of 236 patients consisting of 219 (92.8%) younger patients and 17 (7.2%) older patients was evaluated. The median ages of the younger and older patients were 34 (interquartile range [IR], 24-45) and 78 years (IR, 74-81), respectively. The prevalence of complicated appendicitis (CA) (older: 41.2% vs. younger: 14.2%), comorbidities (70.6% vs. 13.2%), and thrombocytopenia (17.7% vs. 4.1%), along with serum C-reactive protein (CRP) level (6.7 mg/dl vs. 1.0 mg/dl), was significantly higher in older patients. Significantly fewer older patients had epigastric pain (17.7% vs. 53.0%). Logistic regression evaluating the characteristics of older AA patients showed that CRP >5 mg/dl had a high odds ratio (OR) (5.01; 95% CI, 1.73-14.54), while epigastric pain had a low OR (0.24; 95% CI, 0.06-0.90).

CONCLUSION

Our study reveals a higher prevalence of CA and comorbidities in older patients, and suggests that a lack of epigastric pain, thrombocytopenia, and higher serum CRP level are characteristics of older AA patients.

Major Depression and Onset of Frontotemporal Dementia

PURPOSE

Frontotemporal dementia (FTD) is still a clinical challenge with the highest rate of misdiagnosis and poor outcome. The pathogenetic relationship between depression and neurodegeneration remains unclear. This study evaluated depression prevalence before FTD diagnosis.

PATIENTS AND METHODS

The aim was to assess the prevalence and impact of depression on FTD diagnostic process. The clinical characteristics of 72 patients hospitalized in Department of Affective and Psychotic Disorders Medical University of Lodz between 2010 and 2020 with final diagnosis FTD were analyzed. The data referring to first psychiatric diagnosis, time from first psychopathological symptoms to clarification of FTD diagnosis were collected. The patients who did not undergo full neuropsychiatric verification were excluded from the analysis.

RESULTS

About 69% of patients had other concomitant diagnosis of mental disorders which was made prior to FTD diagnosis. Among this subsample, 71% revealed depression diagnosis with at least moderate severity. The patients whose first diagnosis was psychotic depression revealed the longest period from the appearance of the first psychopathological symptoms to the diagnosis of FTD in comparison to the subsample with other psychiatric diagnosis (p=0.034; mean 4.33±3.28 years vs mean 2.68±1.39 years).

CONCLUSION

The severe depressive symptoms in older age may reflect the development of neurodegeneration before full-blown frontotemporal dementia symptomatology. We hypothesized that psychotic depression is a predictor of FTD. Further investigations in this field are required.