Long-term anti-TNF therapy and the risk of serious infections in a cohort of patients with rheumatoid arthritis: Comparison of adalimumab,etanercept and infliximab in the GISEA registry

ObjectiveTo evaluate the risk of serious infections (SIs) in RA patients receiving anti-TNF therapy on the basis of the data included in the GISEA register.MethodsThe study involved 2769 adult patients with long-standing RA (mean age 53.2 ± 13.4 years; mean disease duration 9.0 ± 8.3 years) enrolled in the GISEA register, who had been treated for at least 6 months with TNF inhibitors or had discontinued therapy due to SI: 837 (30%) treated with infliximab (IFN), 802 (29%) with adalimumab (ADA), and 1130 (41%) with etanercept (ETN).Results176 patients had experienced at least one of the 226 Sis during the 9 years of treatment with an anti-TNF agent, an overall incidence of 31.8/1000 patient-years (95% CI 25.2–38.3): 23.7/1000 patient-years (95% CI 13.1–34.2) on ADA; 12.8/1000 patient-years (95% CI 6.3–19.4) on ETN and 65.1/1000 patient-years (95% CI 48.4–81.8) on IFN. The risk was higher in the first than in the second year of treatment, but this difference was not statistically significant (p = 0.08) (38.9% of the SIs were recorded in the first 12 months of treatment). The risk of SI was significantly different among the three treatment groups (p < 0.0001). Multivariate models confirmed that the use of steroids (p < 0.046), concomitant DMARD treatment during anti-TNF therapy (p = 0.004), advanced age at the start of anti-TNF treatment (p < 0.0001), and the use of IFN or ADA rather than ETN (respectively p < 0.0001 and p = 0.023) were strong and statistically significant predictors of infection.ConclusionsAnti-TNF therapy is associated with a small but significant risk of SI that is associated with the concomitant use of steroids, advanced age at the start of anti-TNF treatment, and the type of anti-TNF agent.     

Current outcomes of chronic active antibody mediated rejection – A large single center retrospective review using the updated BANFF 2013 criteria

BackgroundThe updated BANFF 2013 criteria has enabled a more standardized and complete serologic and histopathologic diagnosis of chronic active antibody mediated rejection (cAMR). Little data exists on the outcomes of cAMR since the initiation of this updated criteria.Methods123 consecutive patients with biopsy proven cAMR (BANFF 2013) between 2006 and 2012 were identified.ResultsPatients identified with cAMR were followed for a median of 9.5 (2.7–20.3) years after transplant and 4.3 (0–8.8) years after cAMR. Ninety-four (76%) recipients lost their grafts with a median survival of 1.9 years after diagnosis with cAMR. Mean C4d and allograft glomerulopathy scores were 2.6 ± 0.7 and 2.2 ± 0.8, respectively. 53.2% had class II DSA, 32.2% had both class I and II, and 14.5% had class I DSA only. Chronicity score >8 (HR 2.9, 95% CI 1–8.4, p = 0.05), DSA >2500 MFI (HR 2.8, 95% CI 1.1–6.8, p = 0.03), Scr >3 mg/dL (HR 3.2, 95% CI 1.6–6.3, p = 0.001) and UPC >1 g/g (HR 2.5, 95% CI 1.4–4.5, p = 0.003) were associated with a higher risk of graft loss.ConclusionscAMR was associated with poor graft survival after diagnosis. Improved therapies and earlier detection strategies are likely needed to improve outcomes of cAMR in kidney transplant recipients.     

Minimally invasive total knee arthroplasty; a pragmatic randomised controlled trial reporting outcomes up to 2 year follow up

BackgroundWe present a prospective, randomised, multi-surgeon, controlled trial comparing minimally invasive (MIS) and standard approach total knee arthroplasty (TKA).MethodsParticipants underwent unilateral TKA. Patients were randomised to Bristol, quadriceps sparing MIS or standard medial parapatellar approaches. Length of stay with secondary outcome measures including knee range of movement, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) and American Knee Society Score (KSS) up to 2 years. Radiographic and post operative assessment was blinded.Results86 patients (92 knees) participated in the study. Mean operative time between MIS and control groups was 95.5 (95% CI 90.0–101.0) and 94.8 (95% CI 88.2–101.4) minutes respectively. Mean readiness for discharge was shorter in the MIS group 4.5 ± 1.5 (95% CI, 4.1–4.9) days versus 5.9 ± 2.7 (95% CI, 5.1–6.7) days amongst controls (p = 0.004). Patients in the MIS group had fewer complications (p = 0.003). One patient developed a deep vein thrombosis (DVT) and one required revision surgery, both in the control group.83 patients completed follow up to 2 years (40 MIS, 43 controls). Range of movement and other outcome measures improved up to 1 year post-operatively with no statistically significant differences between MIS and controls. We found no evidence of radiographic loosening in either group at the 2 year follow up.ConclusionsMIS offers reduced length of stay and fewer complications for patients following TKR without evidence of component mal-alignment. Our findings of fewer systemic complications in MIS TKR patients warrant further future study.Level of evidenceLevel 1     

Nerve-sparing radical hysterectomy versus conventional radical hysterectomy in early-stage cervical cancer. A systematic review and meta-analysis of survival and quality of life

Background and aimsSurvival after radical hysterectomy (RH) for early-stage cervical cancer is good. Hence quality of life (QOL) after treatment is an important issue. Nerve-sparing radical hysterectomy (NSRH) improves QOL by selectively sparing innervation of bladder, bowel and vagina, reducing therapy-induced morbidity. However, the oncological outcome and the functional outcome after NSRH are subjects of debate. We aim to present the best possible evidence available regarding both QOL and survival after NSRH in early-stage cervical cancer.MethodsSystematic review and meta-analysis on studies comparing NSRH and RH.ResultsForty-one studies were included, and 27 were used for the meta-analysis. There was no difference in 2-, 3- and 5-year overall survival: the risk ratios (RRs) were respectively 1.02 (95% CI 0.99–1.05, n = 879), 1.01 (95% CI 0.95–1.08, n = 1324) and 1.03 (95% CI 0.99–1.08, n = 638). No difference was found in 2-, 3- and 5-year disease-free survival: RR 1.01 (95% CI 0.95–1.05, n = 1175), 0.99 (95% CI 0.94–1.03, n = 1130) and 1.00 (95% CI 0.95–1.06, n = 933) respectively. Post-operative time to micturition was significantly shorter in the NSRH group: standardized mean difference (SMD) −0.84 (CI 95% −1.07 to −0.60).ConclusionsNSRH can be considered safe and effective for early-stage cervical cancer since short- and long-term survival do not differ from those of conventional RH, while bladder function after NSRH is significantly less impaired.     

Performance of a new rapid test for detecting anti-hepatitis E virus immunoglobulin M in immunocompetent and immunocompromised patients

BackgroundHepatitis E virus (HEV) infections are widespread in both developing and developed countries. It is, therefore, important to assess the performance of systems for rapidly detecting anti-HEV immunoglobulin M antibodies in human sera.ObjectivesTo evaluate the diagnostic value of a new immunochromatographic assay, the HEV IgM rapid test (Wantai).Study designBlood samples were taken from 30 acutely infected immunocompetent and 30 acutely infected immunocompromised patients, all with HEV RNA in their blood. Specificity and cross reactivity was assessed using samples from 30 HEV RNA negative immunocompetent patients who had acute Epstein–Barr virus (EBV) or cytomegalovirus (CMV) infections and 30 HEV RNA negative immunocompromised patients. The performance of the HEV IgM Rapid Test was compared to that of a conventional microplate enzyme immunoassay.ResultsThe sensitivity of the rapid test in immunocompetent patients was 90% (95% CI: 72.1–100%), similar to that of the Wantai microplate assay (sensitivity: 96.6%, 95% CI: 78.77–100%; p = 0.61). The sensitivity of the rapid test in immunocompromised patients was 73.3% (95% CI: 55.4–91.2%) and that of the microplate assay was 83.3% (95% CI: 65.44–100%; p = 0.53). The rapid test produced no false positive reactions with samples from HEV RNA negative patients; while the microplate assay gave two false positive results (3.3%).ConclusionThe new Wantai HEV IgM rapid test is easy to use and suitable for rapidly detecting acute hepatitis E infections in both immunocompetent and immunocompromised patients. However, HEV RNA must be detected using a molecular assay for diagnosing an HEV infection in anti-HEV IgM negative patients.     

Dengue virus infection during pregnancy increased the risk of adverse fetal outcomes? An updated meta-analysis

ObjectiveTo evaluate the effect of maternal dengue virus (DENV) infection during pregnancy in premature birth, low birth weight, miscarriage and stillbirth.MethodsSystematic electronic literature searches were conducted including PubMed, Medline, Embase, Web of science, Scopus and the Cochrane Library database, up until July 5, 2017. Effect sizes were estimated by using the relative risk (RR) or odds ratio (OR) with theirs corresponding 95% confidence interval (CI). Subgroup analyses were conducted for study design (prospective or retrospective) and clinical symptom of participants (symptomatic or asymptomatic). Statistical analysis was conducted by STATA 12.0.ResultsThe initial systematic literature searches identified 1048 studies. After screening, fourteen studies were included. The pooled results did not suggest maternal DENV infection might increase the risk of adverse fetal outcomes with a pooled RR of 0.96 (95% CI: 0.85–1.09, I² = 49.6%) for premature birth, RR of 0.99 (95%CI: 0.87–1.12, I² = 35.1%) for low birth weight, OR of 1.77 (95% CI: 0.99–3.15, I² = 17.5%) for miscarriage and RR of 3.42 (95% CI: 0.76–15.49, I² = 54.8%) for stillbirth. Subgroup analysis of studies in symptomatic participants still did not indicate DENV infection appeared to be a risk factor for premature birth, low birth weight and miscarriage with pooled effect size of 0.99 (95% CI: 0.87–1.13, I² = 49.3%), 1.22 (95% CI: 0.827–1.80, I² = 55.1%) and 1.19 (95% CI: 0.56–2.55, I² = 4.7%), respectively.ConclusionsCurrent evidence did not suggest that maternal DENV infection during pregnancy might increase the risk of premature birth, low birth weight, miscarriage and stillbirth.     

Mobile bearing or fixed bearing? A meta-analysis of outcomes comparing mobile bearing and fixed bearing bilateral total knee replacements

BackgroundTo compare outcomes between mobile-bearing (MB) and fixed-bearing (FB) in bilateral total knee replacements.MethodsThe MEDLINE, EMBASE and Cochrane Library databases were searched. Randomized controlled trials of bilateral total knee arthroplasty with one of each design implanted were identified. Weighted mean differences (WMDs) and pooled risk ratios (RRs) were calculated using fixed- or random-effects models.ResultsTwelve studies were identified with a total of 807 patients and 1614 knees. All RCTs were of high quality with a low risk of bias. No statistical difference was found between MB and FB at 2- to 5-year follow-up in terms of America Knee Society score (WMD: − 1.29, 95% CI: − 5.65 to 3.06), pain score (WMD: − 3.26, 95% CI: − 10.45 to 3.93), range of motion (WMD: − 4.16, 95% CI: − 9.97 to 1.66), reoperation (RR: 1.00, 95% CI: 0.28 to 3.60), and radiolucent lines (RR: 1.51, 95% CI: 0.70 to 3.24). The results were similar at 1-, 5- to 8-, or > 8-year follow-up. Patient's satisfaction (RR: 0.85, 95% CI: 0.54 to 1.34), and complication (≤ 2-year, RR: 0.55, 95% CI: 0.29 to 1.04; > 2-year, RR: 1.0, 95% CI = 0.73 to 1.38) also showed no difference between two groups.ConclusionsBased on this meta-analysis we are unable to detect the superiority of MB as compared to FB. More randomized trials with a larger sample size and longer follow-up are needed to evaluate these two kinds of prosthesis.Level of evidenceTherapeutic Level II.     

Providing prenatal care to pregnant women with overweight or obesity: Differences in provider communication and ratings of the patient-provider relationship by patient body weight

ObjectiveTo examine the association of women’s body weight with provider communication during prenatal care.MethodsWe coded audio recordings of prenatal visits between 22 providers and 117 of their patients using the Roter Interaction Analysis System. Multivariate, multilevel Poisson models were used to examine the relationship between patient pre-pregnancy body mass index and provider communication.ResultsCompared to women with normal weight, providers asked fewer lifestyle questions (IRR 0.66, 95% CI 0.44–0.99, p = 0.04) and gave less lifestyle information (IRR 0.51, 95% CI 0.32–0.82, p = 0.01) to women with overweight and obesity, respectively. Providers used fewer approval (IRR 0.68, 95% CI 0.51–0.91, p = 0.01) and concern statements (IRR 0.68, 95% CI 0.53–0.86, p = 0.002) when caring for women with overweight and fewer self-disclosure statements caring for women with obesity (IRR 0.40, 95% CI 0.19–0.84 p = 0.02).ConclusionLess lifestyle and rapport building communication for women with obesity may weaken patient-provider relationship during routine prenatal care.Practice implicationsInterventions to increase use of patient-centered communication – especially for women with overweight and obesity – may improve prenatal care quality.     

The prognosis of highly active antiretroviral therapy (HAART) treated HIV infected patients in Serbia,related to the time of treatment initiation

BackgroundWith the introduction of highly active antiretroviral treatment (HAART) an impressive improvement in patient survival and quality of life has bee observed. However, the optimal timing of initial HAART is still under consideration.ObjectiveTo investigate the prognosis of HAART treated patients in Serbia, related to the timing of HAART initiation.Study designA series of 563 patients on HAART was retrospectively analyzed to investigate treatment response and survival.ResultsAfter a mean of 6 years (range 1–14) of treatment with PI-based and/or NNRTI-based regimens, a favorable response was achieved in 72.4%, treatment failure occurred in 7.9%, while 19.7% had a dissociative immunological/virological response. If treatment was initiated during primary HIV infection it took a shorter time to achieve a favorable response than in patients who began HAART in chronic HIV infection (2.7 ± 2.2 years vs. 6.9 ± 2.7 years, P < 0.01). A higher proportion of patients with primary HIV infection then those treated in the chronic phase achieved a favorable response to HAART (88.4% vs. 71.9%, P = 0.045). Patients who initiated HAART when their CD4 cell counts were below 200 cells/μL needed longer treatment for favorable response (8 years vs. 6 years, log rank P < 0.01). Forty-seven (8.3%) patients died. The overall estimated survival was 13 years. Patients older then 40 and IVDU were more likely to die during HAART (OR 2.6, 95% CI 1.1–5.9, P = 0.016, and OR 2.0, 95% CI 1.0–3.7, P = 0.02, respectively). However, reaching and maintaining undetectable viremia was an independent predictor of longer survival (OR 11.3, 95% CI 4.6–27.7, P < 0.01).ConclusionReaching and maintaining undetectable viremia during HAART predicted longer survival, even if sub-clinical immunodeficiency remained.     

Association between IFNL4 rs368234815 polymorphism and sustained virological response in chronic hepatitis C patients undergoing PEGylated interferon/ribavirin therapy: A meta-analysis

Background and aimsMany studies have been published on the association between IFNL4 rs368234815 single-nucleotide polymorphism (SNP) and sustained virological response (SVR) in chronic hepatitis C (CHC) patients undergoing treatment with PEGylated interferon (PEG-IFN) plus ribavirin (RBV). Because of the variable and sometimes inconsistent results, we performed a meta-analysis to estimate the association between these factors.MethodsWe conducted a search of the literature published prior to July 1, 2014. The pooled results were analyzed as the odds ratios (ORs) and corresponding 95% confidence intervals (CIs) using random-effect model.ResultsThe pooled results revealed that the rs368234815 TT/TT genotype was significantly correlated with SVR in HCV-1/4-infected Caucasian patients (OR = 4.65, 95% CI = 3.36–6.42, P < 0.00001) but not in HCV-2/3-infected Caucasian patients (OR = 1.44, 95% CI: 0.89–2.33, P = 0.13). Conversely, the rs368234815 ΔG/ΔG genotype was significantly linked to treatment failure in Caucasian patients (OR = 0.49, 95% CI: 0.38–0.64, P < 0.00001), regardless of the HCV genotype.ConclusionThe results of the meta-analysis suggest that IFNL4 rs368234815 polymorphism may be a predictor of SVR in Caucasian HCV-1/4-infected patients.     

Comparison the effect of lateral wedge insole and acupuncture in medial compartment knee osteoarthritis: A randomized controlled trial

BackgroundThere is lack of well-designed trials evaluating structural benefits of non-pharmacologic therapies in knee osteoarthritis (OA). In this parallel-group randomized controlled trial, we aim to compare the possible advantages of lateral wedge insole and acupuncture in patients with medial knee OA.MethodPatients with grade two or three of medial knee OA were randomly allocated to group one who received an in shoe lateral wedge and group two who underwent acupuncture. We assessed patients' pain, function and knee joint cartilage thickness before and after intervention. Paired t-test and independent samples t-test were used for in group and between group analyses. (Level of evidence: 2.)ResultsTwenty patients in each group were recruited in the study. Pain significantly decreased after therapy in both groups one and two (paired t test, P < 0.001, 95% CI: 1.62–3.25 and 1.58–3.20 respectively). Function improved in each group (paired t test, P = 0.001, 95% CI of 0.94–2.38 in group one and 0.97–2.43 in group two). A non-clinically statistically significant difference regarding the femoral and tibial cartilage thickness was obtained in both groups one (P = 0.005, CI: − 0.43–0.82 and P = 0.037, CI: − 0.44–0.80 respectively) and two (P = 0.025, CI: − 0.45–0.79 and P = 0.035, CI: − 0.29–0.96 respectively). Between groups analysis showed no significant difference regarding abovementioned measures.ConclusionBoth lateral wedge insole and acupuncture can be effective in the treatment of medial knee osteoarthritis without any superiority of one over the other.Iranian Registry of Clinical Trials: IRCT201201108235N1.URL: http://irct.ir/searchen.php     

Elevated chemokine levels during adult but not pediatric Crimean–Congo hemorrhagic fever

BackgroundCrimean–Congo hemorrhagic fever (CCHF) is a tick-borne viral zoonosis. Clinical reports indicate the severity of CCHF is milder in children than adults. The chemokines are important chemo-attractant mediators of the host immune system.ObjectivesThe main aim of the study was to identify whether or not there were any differences in chemokine levels between the pediatric and adult patients and control groups, and whether there was any correlation with disease severity.Study designThe serum levels of select chemokines including chemokine (C-C) ligand 2 (CCL2), CCL3, CCL4, chemokine (C-X-C) ligand 8 (CXCL8), CXCL9, and granulocyte-colony stimulating factor (G-CSF) in 29 adult and 32 pediatric CCHF patients and in 35 healthy children and 40 healthy adult control groups were studied by flow cytometric bead immunoassay method.ResultsGreat variability was detected in the serum levels of the chemokines for both the adult and pediatric patients and controls. With the exception of G-CSF, the median serum levels of CCL2, CCL3, CCL4, CXCL8, and CXCL9 were found to be significantly higher in the adult patients compared to adult controls (2364.7 vs. 761 pg/ml; 714.1 vs. 75.2 pg/ml; 88.6 vs. 25.5 pg/ml; 217.9 vs. 18.3 pg/ml; 875 vs. 352.2 pg/ml, respectively, p < 0.0001 for all comparisons). Among the chemokines the median CCL4 and G-CSF levels were significantly higher in the pediatric patients compared to pediatric controls (40.3 vs. 7.1 pg/ml, p < 0.0001; 0.1 vs. 0.1 pg/ml, p = 0.049, respectively).ConclusionThe results of this study showed prominent chemokine raising in adult CCHF patients compared to children CCHF patients.     

CMV plasma DNAemia and risk of cancer among HIV-infected patients: A case–control study nested in the ANRS CO3 Aquitaine Cohort,France, 2002–2007

BackgroundCMV reactivation, which enhances immune senescence, could be associated with a higher risk of cancer.ObjectivesWe compared the prevalence of positive CMV DNAemia in HIV-infected patients with and without cancer.Study designThis case–control study, nested in the ANRS-CO3 Aquitaine Cohort, included patients with a first diagnosis of cancer (2002–2007) as cases. Two controls were matched per case.Cancer risk was estimated using conditional logistic regression models, an Odds Ratio (OR) of 2 could be detected with 80% power. The variables considered were: ≥1 positive CMV DNAemia, CD4+ and CD8+ counts, HIV plasma load. Plasma CMV DNA was retrospectively quantified within the 3-year period preceding the endpoint.ResultsThe 143 cases (93 non-AIDS-related and 50 AIDS-related cancers) and 284 controls had a median age of 47 years (IQR: 41–56). At the time of diagnosis or censorship, for cases and controls, median values were respectively, for CD4+ count: 327 cells/mm³ (IQR: 164–514) and 416 (IQR: 275–582), and for HIV plasma load: 2.6 log₁₀ copies/mL (IQR: 1.7–4.7) and 1.7 log₁₀ copies/mL (IQR: 1.7–3.3). We performed 2056 CMV PCR; 14 cases (9.8% [95% CI: 4.9–14.7]) and 19 controls (6.7% [CI: 3.8–9.6]) presented ≥1 positive PCR. CMV DNAemia was not associated with the risk of cancer (unadjusted and adjusted p-values = 0.19 and 0.54, respectively). HIV load >500 copies/mL was independently associated with a higher risk of cancer (OR = 2.02; p = 0.002; 95% CI: 1.29–3.17).ConclusionThis large case–control study did not show any differential exposure to positive CMV plasma DNAemia between cancer cases and controls.     

Evaluation of a new rapid influenza A diagnostic test for detection of pandemic (H1N1) 2009 and seasonal influenza A virus

BackgroundRapid influenza A diagnostic tests (RIDTs) play an important role in the clinical setting, especially in the influenza post-pandemic era with three influenza A viruses in circulation.ObjectivesDetermine the sensitivity and specificity of a new RIDT (FluA Dot) by comparison with BD Directigen EZ FluA+B and CDC rRT-PCR.Study designTwo sets of experiments were conducted to determine the performance of the new test. (1) Serial dilutions of eight pandemic (H1N1) 2009 (pH1N1) isolates, five seasonal H3N2 isolates, five seasonal H1N1 isolates and three recombinant nucleoproteins were tested by FluA Dot assay, Directigen EZ FluA+B test and CDC real-time RT-PCR. (2) Using CDC rRT-PCR as the gold standard, the clinical sensitivity and specificity of the FluA Dot and Directigen EZ FluA+B were evaluated in nasopharyngeal swab (NPS) specimens of 807 patients presenting with influenza-like illness.ResultsThe average analytical sensitivity of FluA Dot (0.06 ng/mL for recombinant nucleoproteins and 2.16 ± 0.85 log 10 TCID₅₀ for viruses) was approximately 10-fold higher than Directigen EZ FluA+B (1–2 ng/mL for recombinant nucleoproteins and 3.54 ± 0.81 log 10 TCID₅₀ for viruses), and was approximately 10-fold lower than the CDC rRT-PCR (1.09 ± 0.69 log 10 TCID₅₀ for viruses). Among 807 NPS specimens tested, the sensitivities and specificities of FluA Dot were 91.1% (95%CI: 86.7–94.4%)/99.7% (95%CI: 98.7–99.9%), and the Directigen EZ FluA+B were 71.9% (95%CI: 65.7–77.6%)/99.8%(95%CI: 99.0–99.9%).ConclusionThe new test (FluA Dot) exhibit higher sensitivity than Directigen EZ FluA+B both in pH1N1 and seasonal influenza A detection. The promising RIDT can play important roles in influenza diagnosis and therapy.     

Pulmonary hypertension in systemic lupus erythematosus: prevalence,predictors and diagnostic strategy

ObjectivesTo investigate the prevalence and predictors of pulmonary hypertension (PH) in patients with systemic lupus erythematosus (SLE) and to validate a diagnostic strategy.Methods245 patients with SLE entered a screening program. Possible PH was defined as two consecutive systolic pulmonary arterial pressure (PAP) values ≥ 40 mm Hg by echocardiography. The subsequent diagnostic procedure, including right heart catheterization if needed, confirmed or excluded the diagnosis of PH secondary to cardiopulmonary disease or SLE-related pulmonary arterial hypertension (PAH). Independent predictors of PH were identified by multivariant multiple linear or logistic regression models. The sensitivity (S), specificity (SP), positive (PPV) and negative predictive values (NPV) were calculated for different screening cutoff values.Results88% patients were women. The mean (SD) age at the time of enrolment was 45 (16) years. 12 cases of PH were detected, all secondary, with a resulting prevalence of 5%. Two consecutive echocardiographic PAP measurements ≥ 40 mm Hg performed best as the cutoff point for screening (S 100%, SP 97%, PPV 70, NPV 100), as compared with single PAP measurements ≥ 30 mm Hg or ≥ 40 mm Hg The age at the time of enrolment was the only variable independently associated with PAP values (p = 0.0001), with the SLICC damage index score showing a borderline association (p = 0.08). Only the age at the time of enrolment showed an independent association with PH (OR 1.10, 95% CI 1.06–1.17).ConclusionWe found a low prevalence of PH. Screening echocardiograms in asymptomatic lupus patients are thus not recommended. Two consecutive PAP values ≥ 40 mm Hg by echocardiogram is the best screening cutoff for starting investigations in SLE patients with suspected PH.     

The effectiveness of routine laboratory findings in determining disease severity in patients with Crimean-Congo hemorrhagic fever: Severity prediction criteria

BackgroundCrimean-Congo hemorrhagic fever (CCHF) is a potentially fatal disease caused by a tick-borne virus from the Bunyaviridae family.ObjectivesTo determine the predictive criteria for severity among patients with CCHF based on clinical and laboratory findings.Study designThis retrospective study was conducted on patients with CCHF and hospitalized between June 2004 and August 2008 at Karadeniz Technical University, Turkey. Demographic characteristics, clinical findings and laboratory tests on admission of all patients with CCHF were investigated.ResultsA total of 152 patients with confirmed CCHF were investigated. Sixty-three (41.4%) of these patients were in the severe group. Laboratory findings using the ROC curve method and optimum diagnostic cut-off points for specific laboratory parameters in the severe group were; PLT: 90,000, Hb: 13.5 g/dL, PT: 13.1 s, aPTT: 34 s, INR: 1, AST: 117 U/L, ALT: 71 U/L, AST/ALT: 1.62, LDH: 508 U/L, CK: 267 U/L and CRP: 0.59 mg/dL. At multivariable analysis, the risk for a severe clinical course in CCHF patients increased 2.59 and 3.93 times in the presence of platelet count and Hb below cut-off values, whereas the same risk increased 2.95, 2.92 and 3.47 times when the results for INR, AST and CRP, respectively, were above the predetermined cut-off values.ConclusionsA number of laboratory findings that can easily be measured at routine examination of patients hospitalized with a suspicion of CCHF are valuable and sensitive predictors. These parameters will contribute considerably to the design, practice and management of supportive treatment, blood and blood products replacement and intensive care services.     

Circuit resistance training is an effective means to enhance muscle strength in older and middle aged adults: A systematic review and meta-analysis

BackgroundPhysical exercise, particularly resistance training (RT), is proven treatment to reduce the accelerated decline in muscle strength exhibited by older adults, but its effect is hindered by low adherence rate, even under well-structured programs.Objective and data sourcesWe investigated the efficacy of circuit resistance training (CRT) on muscle strength, lean mass and aerobic capacity in older adults based on report in MEDLINE, EMBASE, ClinicalTrials.gov and Cochrane electronic (through 8/2016). Study eligibility criteria: middle and older aged men and/or women who followed a structured program, assigned to CRT. Study appraisal and synthesis methods: Out of 237 originally identified articles, 10 articles were included with a total of 362 patients with mean: age −64.5 ± 7.4 years; 3 ± 1.15 sessions/week; session duration 41.8 ± 15.9 min.ResultsUpper body strength modestly increased, by 1.14 kg (95% CI; 0.28–2.00), whereas larger increment was seen in lower body strength (11.99; 2.92–21.06). Higher program volume (>24 sessions) positively influenced upper body strength and aerobic capacity.Limitations(1) variability in the studies’ validity; (2) relatively low number of studies.ConclusionCRT is a valid alternative to conventional RT. Its shorter duration and lower intensity relative to traditional RT, may increase adherence to training in older adults.     

Crucial parameter of the outcome in Crimean Congo hemorrhagic fever: Viral load

BackgroundCrimean Congo hemorrhagic fever (CCHF) is a fatal disease with a mortality rate of 5–30%. CCHF can be asymptomatic or it may progress with bleeding and cause mortality.ObjectivesTo evaluate relation of viral load with mortality, clinical and laboratory findings in CCHF.Study designA total of 126 CCHF patients were included. Serum samples obtained from all patients on admission for measurement of viral load.ResultsIn our study, mortality rate was 11.1%. The most important prognostic factor was viral load. Mean viral load was 8.3 × 10⁷ copy/ml and 4.6 × 10⁹ copy/ml in survived and dead patients, respectively (p < 0.005). Probability of survival is found to be significantly reduced where AST >1130 U/l, ALT >490 U/l, CPK >505 U/l, LDH >980 U/l, platelet count <23 × 10³/l, creatinine >1.4 mg/dl, INR >1.3, d-dimer >7100 ng/dl, and viral load >1.03 × 10⁸ copy/ml. Patients with 10⁸ copy/ml or higher viral load had diarrhea, headache, unconsciousness, bleeding, and seizure significantly more frequently (p < 0.05). WBC, hemoglobin, platelet counts were significantly lower whereas AST, ALT, CPK, LDH, creatinine levels, PT and aPTT time, d-dimer levels, and INR were found to be significantly higher in these group.ConclusionsThere are several severity criteria for prognosis of CCHF. In addition to these parameters, we introduce creatinine as a predictive factor for prognosis. Our study, which has the largest number of patients among studies that evaluate viral load on CCHF shows that viral load is the most effective parameter on mortality.     

Association of IL-1β +3953 C and HLA-DRB1*15 with Coronary Artery and Rheumatic Heart Diseases in South India

Among the various candidate genes predisposing for cardiovascular diseases, HLA-DRB1* and IL-1β +3953C/T alleles have been implicated repeatedly. To test these in South India, we carried out a case control study of 323 Coronary Artery Disease (CAD) patients, 56 Rheumatic Heart Disease (RHD) patients and 254 endemic controls. The polymorphisms were studied by PCR – SSP and ARMS-PCR methods and results analyzed for various clinical and demographic parameters. In CAD, HLA-DRB1*14 allele showed significant predisposition (OR: 2.19; 95% CI: 1.04–4.58; p value = 0.023), particularly in male patients (OR: 4.07; 95% CI: 1.20–13.81; p value = 0.01) and further in males with Triple Vessel Disease (OR: 5.49; 95% CI: 1.45–20.60; p value = 0.007). On the other hand, HLA-DRB1*15 predisposed for RHD (OR: 3.56; 95% CI: 1.87–6.78; p value = 0.001) in both the genders. Population stratification showed this higher risk association in Vanniyar caste (OR: 5.00; 95% CI: 1.27–19.59; p value = 0.022). Among the IL1-β +3953C/T polymorphism, the ancestral allele ‘C’ showed a significant high risk association with CAD (OR: 1.83; 95% CI: 1.24–2.70; p value = 0.001), particularly in Mudaliar (OR: 6.07; 95% CI: 1.77–20.74; p value = 0.003; AF = 0.7) and Vanniyar castes (OR: 3.67; 95% CI: 0.92–14.57; p value = 0.05; AF = 0.660). Two different cardiac ailments studied, RHD & CAD thus showed varied associations in this South Indian cohorts. RHD having an infectious aetiology shared a HLA-DRB1*15 high risk association, while HLA-DRB1*14 and IL-1β +3953C predisposed for CAD, an inflammatory disorder, reiterating the diverse genetic predisposition of the two cardiac ailments studied.     

Procalcitonin and macrophage inflammatory protein-1 beta (MIP-1β) in serum and peritoneal fluid of patients with decompensated cirrhosis and spontaneous bacterial peritonitis

PurposeSpontaneous bacterial peritonitis (SBP) is the most frequent infection in patients with cirrhosis causing significant mortality which requires rapid recognition for effective antibiotic therapy, whereas ascitic fluid cultures are frequently negative. The aim of this study was to evaluate the SBP diagnostic efficacy of procalcitonin (PCT) and macrophage inflammatory protein-1 beta (MIP-1β) measured in serum and peritoneal fluid.Material/methodsThirty-two participants with liver cirrhosis and ascites were included into the study (11 females and 21 males, mean age 49.5 ± 11.9 years). The peritoneal fluid and venous blood were collected for routine laboratory examinations and measurements of PCT and MIP-1β. Patients were divided into two groups according to the ascitic absolute polymorphonuclear leukocytes count (≥250 mm⁻³ and <250 mm^–3).ResultsAscites was sterile in 22 participants and SBP was diagnosed in 10 patients. Serum and ascitic levels of PCT and MIP-1β did not correlate with clinical and routine laboratory parameters. MIP-1β in the ascitic fluid was significantly higher in patients with SBP (213 ± 279 pg/ml vs. 66.3 ± 49.8 pg/ml; p = 0.01). The sensitivity and specificity for diagnosis of SBP with ascitic MIP-1β were 80% and 72.7%, respectively (cut-off value 69.4 pg/ml) with AUROC 0.77 (95%CI 0.58–0.96). Serum levels of MIP-1β showed lower diagnostic yield. Serum and ascitic PCT levels were not different in patients with and without SBP.ConclusionsMIP-1β concentration in ascitic fluid may distinguish patients with and without SBP with satisfactory sensitivity and specificity. Chemokines should be further explored for diagnostic use.