Showing papers in "Romanian Journal of Internal Medicine in 2020"

Clinical and laboratory findings from patients with COVID-19 pneumonia in Babol North of Iran: a retrospective cohort study.

Abstract: BACKGROUND: In December 2019, China has experienced an outbreak of novel coronavirus disease 2019 (COVID-19). Coronavirus has now spread to all of the continents. We aimed to consider clinical characteristics, laboratory data of COVID-19 that provided more information for the research of this novel virus. METHODS: We performed a retrospective cohort study on the clinical symptoms and laboratory findings of a series of the 100 confirmed patients with COVID-19. These patients were admitted to the hospitals affiliated to Babol University of Medical Sciences (Ayatollah Rohani, Shahid Beheshti and Yahyanejad hospitals) form 25 February 2020 to 12 March 2020. RESULTS: Nineteen patients died during hospitalization and 81 were discharged. Non-survivor patients had a significantly higher C-reactive protein (CRP) (MD: 46.37, 95% CI: 20.84, 71.90; P = 0.001), white blood cells (WBCs) (MD: 3.10, 95% CI: 1.53, 4.67; P < 0.001) and lower lymphocyte (MD: -8.75, 95% CI: -12.62, -4.87; P < 0.001) compared to survivor patients Data analysis showed that comorbid conditions (aRR: 2.99, 95% CI: 1.09, 8.21, P = 0.034), higher CRP levels (aRR: 1.02, 95% CI: 1.01, 1.03, P = 0.044), and lower lymphocyte (aRR: 0.82, 95% CI: 0.73, 0.93, P = 0.003) were associated with increased risk of death. CONCLUSIONS: Based on our findings, most non-survivors are elderly with comorbidities. Lymphopenia and increased levels of WBCs along with elevated CRP were associated with increased risk of death. Therefore, it is best to be regularly assessed these markers during treatment of COVID-19 patients.

Sepsis, a 2020 review for the internist.

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

The consequences of the COVID-19 pandemic on perceived stress in clinical practice: Experience of Doctors in Iraqi Kurdistan.

Abstract: Introduction. The healthcare workers are at high risk of developing stress-related problems during outbreaks. This study aimed to explore the perceived stress and its relation to the duration of dealing with COVID-19 patients in medical doctors.Methods. The doctors who work in different medical settings in Iraqi Kurdistan during coronavirus outbreak were invited into this cross-sectional study. The doctors were invited from one pediatric, one emergency, one special corona, and one maternity and gynecology hospital. The "Perceived Stress Scale-10 (PSS)" measured the perceived degree of a doctor who experienced stress. The information was collected through a web-based technique to avoid the disease spread.Results. Doctors' mean duration of dealing with suspected/confirmed cases of COVID-19 was 1.2 (Range: 0-16 days). The mean stress score was 18.81 out of 40. Most of the doctors had a moderate level of stress (69.4%), followed by a low (21.1%) and a high level of stress (9.6%). The general physicians and medical lab specialties had higher stress scores; 21.56 and 19.88, respectively. The high level of stress was among general physicians and community and family medicine doctors; 20.0% and 25.0%, respectively. Whether or not doctors dealt with suspected/confirmed cases of COVID-19, did not have a significant difference over the perceived stress score; 19.02 vs. 18.87; P = 0.786). The mean score of stress was raised with increasing duration of dealing with suspected/confirmed cases of COVID-19; r = 0.202; P = 0.004 and decreased with increasing age (r = -0.141; P = 0.045), and clinical experience (r = -0.139, P = 0.048).Conclusion. This study showed that medical doctors are at a moderate level of perceived stress during the COVID-19 outbreak in Iraqi Kurdistan.

Anticoagulant protein S in COVID-19: low activity, and associated with outcome.

Abstract: Introduction. COVID-19 disease was associated with both thrombo-embolic events and in-situ thrombi formation in small vessels. Antiphospholipidic antibodies were found in some studies.Aim. Assessment of protein S activity in patients with COVID-19 as a cause of this prothrombotic state, and of the association of protein S activity with worse outcome.Methods. All patients admitted for COVID-19 disease in a university hospital between 15th of May and 15th of July 2020 were prospectively enrolled into this cohort study. Patients treated with antivitamin K anticoagulants and with liver disease were excluded. All patients had protein S activity determined at admission. The main outcome was survival, while secondary outcomes were clinical severity and lung damage.Results. 91 patients were included, of which 21 (23.3%) died. Protein S activity was decreased in 65% of the patients. Death was associated with lower activity of protein S (median 42% vs. 58%, p < 0.001), and the association remained after adjustment for age, inflammation markers and ALAT. There was a dose-response relationship between protein S activity and clinical severity (Kendall_tau coefficient = -0.320, p < 0.001; Jonckheere-Terpstra for trend: p < 0.001) or pulmonary damage on CT scan (Kendall_tau coefficient = -0.290, p < 0.001; Jonckheere-Terpstra for trend: p < 0.001). High neutrophil count was also independently associated with death (p = 0.002).Conclusion. Protein S activity was lower in COVID-19 patients, and its level was associated with survival and disease severity, suggesting that it may have a role in the thrombotic manifestations of the disease.

Serum malondialdehyde (MDA) level as a potential biomarker of cancer progression for patients with bladder cancer.

Abstract: INTRODUCTION Bladder cancer is the most common malignancy involving the urinary system. Recent research tends to emphasize the role of oxidative stress products in the carcinogenesis of bladder cancer. The level of oxidative stress can be measured by assessing the MDA levels. This study aimed to evaluate serum MDA levels in patients with bladder cancer, as well as to determine its potential role as a biomarker in the diagnosis of the disease and progression risk considerations. METHODS The study was designed as a cross-sectional study and included 90 patients, divided into three groups with 30 patients each: Ta, T1and T2-T4 group, based on histopathological findings after transurethral resection of the tumor. The control group included 30 healthy volunteers. MDA level was determined using the spectrophotometric method. RESULTS Serum MDA level in patients with bladder cancer [0.86 (0.78-1.05) μmol/L] was significantly higher than the serum MDA level in control group [0.70 (0.69-0.72) μmol/L] (p < 0.001). Serum MDA level in Ta group [0.73 (0.70-1.05) μmol/L], T1 group [0.85 (0.80-1.12) μmol/L] and in T2-T4 group [0.91 (0.84-1.04) μmol/L] was significantly higher than the serum MDA level in control group [0.70 (0.69-0.72) μmol/L] (p < 0.01). MDA level in T1 and T2-T4 group was significantly higher than the MDA level in Ta group (p < 0.01). No significant difference was observed in MDA level between T1 and T2-T4 group (p = NS). A statistically significant positive correlation was found between tumor size and serum MDA level in patients with bladder cancer (rho = 0.254 p < 0.01). CONCLUSIONS The results of the present study suggest that MDA serum level might play a significant role as a biomarker in the diagnosis of bladder cancer, as well as in the monitoring of its progression.

Update on Kaposi sarcoma-associated herpesvirus (KSHV or HHV8) - review.

Abstract: Human herpesvirus 8 (HHV8), also known as Kaposi sarcoma-associated herpesvirus (KSHV), is one of the few pathogens recognized as direct carcinogen, being involved in the pathogenesis of Kaposi sarcoma, primary effusion lymphoma and multicentric Castleman disease. KSHV is a relatively recently discovered virus, with still limited possibilities for diagnosis and treatment. Therefore, ongoing studies are trying to answer the main issues related to the management of KSHV infection and its associated diseases. This review updates the current knowledge of the KSHV infection, discussing aspects related to epidemiology, virological features, clinical manifestations, diagnosis and treatment.

Assessment of severity of acute pancreatitis over time.

Abstract: In recent years there has been an increase in the incidence of acute pancreatitis worldwide. In spite of efforts to improve the treatment and care of patients with acute pancreatitis, to develop imaging investigations and interventional diagnostic and treatment techniques and to facilitate patients' access to them, acute pancreatitis continues to be associated with significant mortality and morbidity, and the treatment of patients suffering from this disease entails significant costs for healthcare systems. Researchers are in a permanent quest to get to a global consensus for stratifying the severity of acute pancreatitis. We need this in order to offer the proper management for each patient diagnosed with this condition and to improve hospital and health system strategies. Over the years, it has been attempted to develop algorithms to support a swift assessment of patients with acute pancreatitis with a prediction of disease severity as close to reality as possible for optimal management. This has led to the development of classifications of severity and severity scores. These require a permanent updating to keep up with the technical and technological developments involved in investigating and treating the patient and encompassing the most recent studies. The goal of this paper is to go through these classifications and scores, emphasizing factors that should be taken into account, and reflecting upon their utility and upon the necessity of improving them.

Gastrointestinal endoscopic practice during COVID-19 pandemic: a multi-institutional survey.

Abstract: Introduction. An on-going coronavirus disease 2019 (COVID-19) has become a challenge all over the world. Since an endoscopy unit and its staff are at potentially high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we conducted a survey for the management of the gastrointestinal endoscopic practice, personal protective equipment (PPE), and risk assessment for COVID-19 during the pandemic at multiple facilities.Methods. The 11-item survey questionnaire was sent to representative respondent of Department of Gastroenterology, Osaka City University Hospital, and its 19 related facilities.Results. A total of 18 facilities submitted valid responses and a total of 373 health care professionals (HCPs) participated. All facilities (18/18: 100%) were screening patients at risk for SARS-CoV-2 infection before endoscopy. During the pandemic, we found that the total volume of endoscopic procedures decreased by 44%. Eleven facilities (11/18: 61%) followed recommendations of the Japan Gastroenterological Endoscopy Society (JGES); consequently, about 35%-50% of esophagogastroduodenoscopy and colonoscopy were canceled. Mask (surgical mask or N95 mask), face shield/goggle, gloves (one or two sets), and gown (with long or short sleeves) were being used by endoscopists, nurses, endoscopy technicians, and endoscope cleaning staff in all the facilities (18/18: 100%). SARS-CoV-2 infection risk assessment of HCPs was conducted daily in all the facilities (18/18: 100%), resulting in no subsequent SARS-CoV-2 infection in HCPs.Conclusion. COVID-19 has had a dramatic impact on the gastrointestinal endoscopic practice. The recommendations of the JGES were appropriate as preventive measures for the SARSCoV-2 infection in the endoscopy unit and its staff.

The cardiovascular complications of diabetes: a striking link through protein glycation.

Abstract: Diabetes mellitus is a predominant cause of mortality and morbidity worldwide. One of its serious health problems is cardiovascular complications. Advanced glycation end products (AGEs) are a group of heterogeneous toxic oxidant compounds that are formed after a non-enzymatic reaction between monosaccharides and free amino groups of proteins, compound lipids, and nucleic acids. AGE interacts with various types of cells through a receptor for AGE (RAGE). The interaction between AGE and RAGE is responsible for a cascade of inflammation, oxidative stress, and disruption of calcium homeostasis in cardiac cells of diabetic patients. There is striking evidence that the AGE/RAGE axis with its consequences on inflammation and oxidative stress plays a major role in the development of cardiovascular complications. Therefore, considering AGE as a therapeutic target with foreseeable results would be a wise direction for future research. Interestingly, several studies on nutraceutical, pharmaceutical, and natural products have begun to reveal promising therapeutic results, and this could lead to better health outcomes for many diabetic patients worldwide. This article discusses the current literature addressing the connection between protein glycation and diabetes cardiovascular complications and suggests future avenues of research.

Role of urinary podocalyxin in early diagnosis of diabetic nephropathy

Abstract: Introduction. Podocyte injury has been reported as an early feature of DN therefore, the assessment of podocyte injury can be accomplished by estimation of podocalyxin in urine. This study aimed to estimate the urinary podocalyxin levels and to determine the sensitivity and specificity of this biomarker for early detection of DN.Materials and methods. A total of 90 patients with type 2 diabetes mellitus (T2DM) were included in this cross-sectional study. Sixty of them were without diagnosed DN, and 30 with diagnosed DN. A control group consisted of 30 healthy subjects. All patients with T2DM were divided into three subgroups according to urinary microalbumin/creatinine ratio (UM/CR): normoalbuminuric, microalbuminuric and macroalbuminuric patients. Urine samples, were used for measurement of podocalyxin by ELISA, creatinine and microalbumin. Fasting venous blood samples was collected for biochemical analyses.Results. The levels of urinary podocalyxin (u-PDX) were higher in patients with T2DM compared to control subjects and a statistically significant difference among studied subgroups regarding u-PDX was found (p < 0.05). Levels of u-PDX are increasing gradually with the degree of DN (p < 0.029). u-PDX levels were positively correlated with UM/CR (r = 0.227, p = 0.002). A cut-off level of 43.8 ng/ml u-PDX showed 73.3% sensitivity and 93.3% specificity to detect DN in early stage. A cut-off level of 30 mg/g UM/CR showed 41.5% sensitivity and 90% specificity in predicting DN. u-PDX was elevated in 48,2% of normoalbuminuric patients.Conclusion. Urinary podocalyxin be useful and more sensitive and specific marker in early detection of DN than microalbuminuria.

Association between serum interleukin (IL)-12 level and severity of non-alcoholic fatty liver disease (NAFLD).

Abstract: What is new? Serum IL-12 level is associated with NAFLD severity. Elevation in serum IL-12 level is in line with more severe NAFLD based on BARD score and NAFLD fibrosis score. Positive correlation is observed between serum IL-12 level and BARD score.Introduction. Non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases worldwide. Lipid accumulation in the liver triggers inflammation and leads to NAFLD. Prolonged inflammation will worsen the disease progression. Pro-inflammatory cytokines, including interleukin (IL)-12, plays a role in the inflammatory process. This study aimed to determine the association between IL-12 and NAFLD severity.Methods. A cross-sectional study was conducted between January and July 2019 in Haji Adam Malik Hospital Medan, Indonesia. Subjects were patients aged 18 years or older diagnosed with NAFLD based on ultrasound. Exclusion criteria were excessive alcohol consumption, other primary liver diseases, malignancies, and cardio-metabolic disturbances. Serum IL-12 level was determined using an enzyme-linked immunosorbent assay method. The severity of NAFLD was assessed using the BARD score and NAFLD fibrosis score.Results. A total of 100 subjects were enrolled with male predominant. The mean age of subjects was 54.97 ± 8.85 years, and the most frequent comorbidity was obesity. Most subjects had mild to moderate disease progression. Serum IL-12 level was higher in more severe NAFLD based on ultrasound grading (P < 0.001), BARD score (P = 0.003), and NAFLD fibrosis score (P = 0.005). A positive correlation was observed between serum IL-12 level and BARD score (P < 0.001) with sufficient accuracy (AUC = 0.691, P = 0.014).Conclusion. Serum IL-12 level was associated with the severity of NAFLD. Higher serum IL-12 level was observed in more severe NAFLD progression.

Candidate proteomic biomarkers in systemic sclerosis discovered using mass-spectrometry: an update of a systematic review (2014–2020)

Abstract: Background. Systemic sclerosis (Ssc) is an autoimmune disease characterized by graduate cutaneous and tissue fibrosis development and irreversible fibroproliferative vascular changes.The aim of the current systematic review was to update the list of proteomic candidate biomarkers identified from Ssc samples with mass spectrometry techniques.Methods. Medline and Scopus databases were searched on 1st September 2020. Relevant articles were searched from March 2014 until September 2020. Two independent reviewers evaluated the retrieved articles.Results. From a total of 97 articles, 9 articles were included in the final analysis summarizing 539 candidate proteomic biomarkers from various samples from Ssc patients (a larger number compared to the previous systematic review). Most biomarkers were identified from cutaneous biopsies. Only 5 articles included a validation step of the findings with only 13 biomarkers being validated.Conclusions. Although many candidate biomarkers were additionally identified, independent validation studies are needed in order to evaluate the importance of these biomarkers for Ssc patients.

Immunosuppressive treatment for peripheral neuropathies in Sjogren’s syndrome – a systematic review

Abstract: Background Sjogren's syndrome (SS) is among the most frequent autoimmune diseases and one of its most severe extraglandular manifestations is peripheral neuropathy. There is no consensus about peripheral neuropathy treatment in SS. Our aim is to identify studies proving the efficiency of immunosuppressive treatment on peripheral neuropathies in SS. Methods The search was conducted on the PubMed (MEDLINE) database. Studies with patients diagnosed with SS and peripheral neuropathy were included. Treatment with one of the following was among inclusion criteria: glucocorticoids (GC), rituximab (RTX), azathioprine (AZA), mycophenolic acid (MMF), cyclophosphamide (CP), methotrexate (MTX), plasmapheresis or iv immunoglobulins (IV IG). Results A total of 116 results were found and abstracts were examined. 103 papers were excluded, and the remaining 13 papers were analyzed. They were 3 case series and 10 case reports, retrospective, totalizing 62 patients of which 22 (35.5%) received IV IG, 8 (13%) received RTX, 7 (11%) CP, and 5 (8%) received only GC. Drug associations containing corticosteroids were frequent. Of those 22 treated with IV IG, 18 patients improved (82%), and 4 stabilized (18%). IV IG was useful in sensory, motor and sensorimotor neuropathies. CP had good results in mononeuritis multiplex, while autonomic neuropathies responded well to GC or RTX. AZA, RTX, MTX, MMF or plasmapheresis were not used alone. Follow-up periods were heterogenous and the evaluation of the neuropathy was not systematic. Conclusion There is only low level evidence (retrospective case reports and case series). In most cases, IV IG treatment in patients with peripheral neuropathies and SS resulted in clinical improvement, while other therapies, such as RTX, corticosteroids and CP proved to be useful in a handful of cases.

Advances in the diagnosis of GERD.

Abstract: Gastroesophageal reflux disease (GERD) is considered one of the most frequent chronic gastrointestinal diseases globally with high costs due to treatment and investigations.First line therapy is with proton pump inhibitors, those who do not respond to initial treatment usually require further investigations such as upper gastrointestinal endoscopy or ambulatory 24-hours esophageal pH monitoring. The total time of exposure to acid and the DeMeester score represent the most useful parameters associated with conventional pH-metry, because they can identify gastroesophageal reflux disease.Although pH-metry is considered the gold standard for the evaluation of gastroesophageal reflux disease, new impedance-based parameters have been introduced in recent years with the role of increasing the accuracy of diagnosing gastroesophageal reflux disease and characterizing the type of reflux. The development of multichannel intraluminal pH-impedance has improved the ability to detect and quantify gastroesophageal reflux. New parameters such as post-reflux swallowing peristaltic wave (PSPW) index and the mean nocturnal basal impedance (MNBI) have recently been introduced to assess GERD phenotypes more accurately. This review evaluates current GERD diagnotic tools while also taking a brief look at newer diagnostic parameters like PSPW and MNBI.

Insulin resistance and testosterone level in Indonesian young adult males.

Abstract: Introduction. Central obesity is characterized by the accumulation of abdominal fat which may lead to several diseases including insulin resistance. The prevalence of central obesity is higherin male and the incidence in young adult males is increased. Central obesity is also related to low testosterone levels. The research aimed to assess the relationship between the testosterone levels and insulin resistance of young adult males with central obesity. Methods. This was a cross-sectional study, the subjects were young adult males of 18 to 25 years old. The central obesity consisted of 50 samples and non-central obesity comprised 70 samples. The examination of testosterone and insulin was performed by the ECLIA method, glucose used the enzymatic method, the insulin resistance was calculated by using the HOMA-IR index. Results. The mean of the testosterone level in central obesity was lower than non-central obesity (5.24 + 1.17 vs 7.18 + 1.54 ng/mL, p < 0.001). HOMA-IR index in central obesity was higher than non-central obesity (4.29 + 2.23 vs 2.46 + 1.72, p < 0.001). Testosterone levels had negative correlation with HOMA-IR (r = –0.470, p < 0.001). There was significant difference in HOMA-IR among the quartiles of testosterone levels. Conclusion. There is negative correlation between testosterone level with HOMA-IR, the lower the testosterone level the higher the insulin resistance in young adult males.

Endoscopic ultrasound-guided drainage of a fungal liver abscess using a lumen-apposing metal stent: case report and literature review

Abstract: Liver abscesses are rare entities for which percutaneous drainage is traditionally employed. The technique is simple, but associated with a significant rate of side effects and patient discomfort. We herein report a case of fungal left liver lobe abscess that was successfully treated by using EUS-guided drainage, with insertion of a large caliber lumen-apposing metal stent. The literature review we performed on the topic seems to favor, at least for abscess in the left and/or caudate liver lobes, EUS as compared to percutaneous drainage.

Interleukin-10 (IL-10) 1082 promoter polymorphisms and plasma IL-10 levels in patients with bacterial sepsis.

Abstract: Background. Interleukin-10 (IL-10) is a multifunctional cytokine which has been seen to play a relevant role in the pathogenesis of sepsis. We examined the association between a single nucleotide polymorphism (SNP) in IL-10-1082G/A in patients with sepsis in Cali city.Methods. A total of 100 patients with sepsis and 50 control subjects were enrolled in this study. Blood samples were collected from all patients in EDTA containing tubes. IL-10-1082G/A gene promoter polymorphism was analyzed by Sequence Specific Polymerase Chain Reaction (SS-PCR), while levels of serum IL-10 were measured by Enzyme Linked Immunoassay Assay (ELISA) in patients with sepsis and healthy controls.Results. AA homozygous genotype was found more frequently in patients (32%), compared with controls (18%). AA homozygous patients showed an increased risk of developing infection by Gram-negative bacteria (OR = 2,875; 95% CI = 1.162-7.113; p = 0.020), and significantly high plasma levels of IL-10 (OR = 4.800, 95% CI 1.652-13.944; p = 0.002). AA homozygous patients high plasma IL-10 levels have greater risk of developing sepsis (63.6%; OR = 4,894; 95% CI: 1,337-17,909; p = 0.002). In this group, Afro-Colombian individuals were overrepresented among the sepsis patients with high plasma IL-10 levels (OR = 1.661; 95% CI: 1.408-1.959; p = 0.036).Conclusion. Our study concluded that AA genotype of IL-10-1082G/A polymorphism is a risk factor for high IL-10 production and development of sepsis by Gram negative bacteria, especially in Afro-Colombian patients.

Stress cardiomyopathy misinterpreted as ST-segment elevation myocardial infarction in a patient with aneurysmal subarachnoid hemorrhage: a case report.

Abstract: Cardiac abnormalities are frequently reported in acute subarachnoid hemorrhage (SAH) patients. However, frank ST-elevation and myocardial dysfunction mimicking acute coronary syndrome is a rare occurrence. Systemic and local catecholamine release mediate myocardial injury and may explain raised troponin levels, concordant regional wall motion abnormalities and systolic dysfunction. These findings can pose a significant problem in the acute setting where "time-is-muscle" paradigm can rush clinicians towards a "rule-in" diagnosis of acute myocardial infarction. We present the case of a 60-year-old male who arrived at a regional emergency department with loss of consciousness, chest pain and headache. His ECG showed ST-elevation in precordial leads with corresponding region wall motion abnormalities and dynamically elevated troponin levels which supported a diagnosis of acute myocardial infarction. Percutaneous coronary intervention was attempted but found no hemodynamically significant lesions and the patient was managed conservatively with antithrombotic treatment. Further work-up for his headache led to the diagnosis of aneurysmal SAH and subsequent endovascular coiling. The patient was discharged with a good clinical outcome. We discuss the potential catastrophic consequences of interpreting neurologic myocardial stunning as STEMI. Use of potent antithrombotic therapies, like bridging thrombolysis, in this setting can lead to dismal consequences. Clinical history should still be carefully obtained in the acute setting in this era of sensitive biomarkers.

Screening for pancreatic cancer: a review for general clinicians.

Abstract: Pancreatic cancer (PC) is an exceptionally lethal malignancy with increasing incidence and mortality worldwide. One of the principal challenges in the treatment of PC is that the diagnosis is usually made at a late stage when potentially curative surgical resection is no longer an option. General clinicians including internists and family physicians are well positioned to identify high-risk individuals and refer them to centers with expertise in PC screening and treatment where screening modalities can be employed. Here, we provide an up-to-date review of PC precursor lesions, epidemiology, and risk factors to empower the general clinician to recognize high-risk patients and employ risk reduction strategies. We also review current screening guidelines and modalities and preview progress that is being made to improve screening tests and biomarkers. It is our hope that this review article will empower the general clinician to understand which patients need to be screened for PC, strategies that may be used to reduce PC risk, and which screening modalities are available in order to diminish the lethality of PC.

Predictors of disease severity and outcome of hospitalized renal transplant recipients with COVID-19 infection: A systematic review of a globally representative sample

Abstract: Introduction. COVID-19 presents a special challenge to the kidney transplant population.Methods. A systematic review of articles that examined COVID-19 in kidney transplant recipients was performed. Patients' demographics, clinical, laboratory and radiological presentations, immunosuppression modification, and COVID-19 specific management were abstracted and analyzed. COVID-19 severity was classified into mild, moderate, and severe. Disease outcome was classified by whether the patient was discharged, still hospitalized, or died.Results. 44 articles reporting individual data and 13 articles reporting aggregated data on 149 and 561 kidney transplant recipients respectively with COVID-19 from Asia, Europe and America fulfilled all inclusion and exclusion criteria. Among studies reporting case specific data, 76% of cases had severe disease. Compared to patients with mild/moderate disease, patients with severe disease had higher CRP, LDH, Ferritin, D-dimer and were more likely to have bilateral lung involvement at presentation and longer time since transplantation (P < 0.05 for all). Recipients' age, gender and comorbidities did not impact disease severity. Patients with severe disease had a more aggressive CNI reduction and more antiviral medications utilization. Outcome was reported on 145 cases, of those 34 (23%) died all with severe disease. Longer duration from transplant to disease diagnosis, hypoxia and higher LDH were associated with mortality (P < 0.05). Different immunosuppression reduction strategies, high dose parenteral corticosteroids use and various antiviral combinations did not demonstrate survival advantage. Similar finding was observed for studies reporting aggregated data.Conclusion. COVID-19 in kidney transplant patients is associated with high rate of disease severity and fatality. Higher LDH and longer time since transplantation predicted both disease severity and mortality. None of the COVID-19 specific treatment correlated with, or improved disease outcome in kidney transplant recipients.

A new approach to cardiac fat volume assessment and the correlation with coronary artery calcification.

Abstract: Background Coronary artery disease (CAD) is the foremost cause of death in the most developed societies. Plaque formation in epicardial coronary arteries and ensuing inflammation are a known pathophysiologic factor of CAD. Objectives We aimed to separately and simultaneously evaluate the correlation between pericardial fat pad volume and overall peri-coronary epicardial adipose tissue (EAT) thickness with coronary calcium score (CCS) to improve risk stratification of CAD. Methods We retrospectively reviewed patients who underwent a non-invasive contrast-enhanced coronary multidetector CT (MDCT) angiography. Peri-coronary EAT thickness, pericardial fat pad volume and CCS were obtained by an expert radiologist from the patients coronary multidetector CT (MDCT) angiography. Results We included 141 symptomatic patients (86 men, 55 women) with an average age of 53.53 ± 12.92. An increment of overall peri-coronary EAT thickness (1/3 × (left anterior descending artery (LAD) + left circumflex artery (LCx) + right coronary artery (RCA)) was associated with a 49% increase in the odds for the presence of coronary artery calcification (CAC) (P = 0.004). Significant predictability of peri-coronary EAT-average was seen in diagnosing calcified plaque. Pericardial fat pad volume was positively correlated with overall peri-coronary EAT thickness in age and body mass index (BMI)-adjusted linear regression models, (P Conclusion Our results amplify previous idea that peri-coronary EAT and pericardial fat pad volume might act as useful markers and better indicators of CCS based on Agatston score in comparison with BMI or body weight in order to reveal subsequent CADs.

Three-tier stratification for CNS COVID-19 to help decide which patients should undergo lumbar puncture with CSF analysis: A case report and literature review.

Abstract: The COVID-19 pandemic continues to overwhelm global healthcare systems. While the disease primarily causes pulmonary complications, reports of central nervous system (CNS) involvement have recently emerged ranging from encephalopathy to stroke. This raises a practical dilemma for clinicians as to when to pursue neuroimaging and lumbar tap with cerebrospinal fluid (CSF) analysis in COVID-19 patients with neurological symptoms. We present a case of an encephalopathic patient infected with SARS-CoV-2 with no pulmonary symptoms. We propose a three-tier risk stratification for CNS COVID-19 aiming to help clinicians to decide which patients should undergo CSF analysis. The neurological examination remains an integral component of screening and evaluating patients for COVID-19 considering the range of emerging CNS complications.

Comparison of anthropometric indices for predicting the risk of metabolic syndrome in older adults.

Abstract: Background. The prevalence of obesity and metabolic syndrome (MetS) is increasing, worldwide. Using a simple, efficient and reliable tool for predicting MetS is an essential approach in preventive health programs. The aim of this study was to compare the different anthropometric indices in predicting metabolic syndrome in older adults.Methods. This cross-sectional study is a part of the Amirkola Health and Ageing cohort Project (2011-2016). Of total, 1,488 older people aged 60-92 years were entered to the study. Medical and personal information of participants were collected by a questionnaire. After measuring the height, weight, waist circumference, hip circumference and neck circumference, body mass index, waist to hip ratio, waist to height ratio, abdominal volume index and conicity index were calculated. Independent t-test, chi-square and ROC curve were used to analyze the data.Results. Based on ATPIII-2005 diagnostic criteria, the prevalence of metabolic syndrome was 71.57%.The prevalence in female was higher than male. All of examined anthropometric indices, except neck circumference (p = 0.10), showed a significant difference in people with MetS compared to the individuals without metabolic syndrome (p<0.001). Waist to height ratio showed the largest area under the curve for predicting MetS (0.786; 95% CI: 0.76-0.81) followed by BMI (0.746; 95% CI: 0.71-0.77), AVI (0.745; 95% CI: 0.71-0.77), and waist circumference (0.743; 95% CI: 0.71-0.77).Conclusion. Waist to height ratio was the best predictor of MetS in older adults.

Aging and nutrition. Paving the way to better health.

Abstract: Sufficient caloric intake is important to maintain the balanced health status, especially during the period of aging, as aging and sickness share paths. Maintaining adequate nutritional balance is the best preventive measure to counteract the risk of malnutrition. There are several causes for malnutrition in elderly people, and some techniques such as anthropometric measurements, laboratory and clinical parameters could help to diagnose malnutrition in these patients. The use of a simple validated questionnaire called the 'Mini Nutritional Assessment' measures the nutritional status of elderly patients. In this review, we discuss about the malnutrition in elderly people with and without a known cause and we present some of nutritional intervention. There are promising strategies that help overcoming malnutrition.

Helicobacter Pylori: a comprehensive review for primary care providers.

Abstract: Helicobacter pylori is the most prevalent bacteria infecting humans resulting in a variety of gastrointestinal and extra gastrointestinal complications. Although most of the infected adults are asymptomatic, the prevalence varies in different parts of the world it is higher in Eastern and Southern Europe. Eradication of Helicobacter pylori is necessary to prevent precancerous conditions like gastric atrophy, gastric intestinal metaplasia and gastric dysplasia. This comprehensive review addresses briefly on: whom and how to test and treat including recommended first line therapies, salvage therapies, testing for eradication and strategy to be used in primary care clinics.

CT-scan Findings of COVID-19 Pneumonia Based on the Time Elapsed from the Beginning of Symptoms to the CT Imaging Evaluation: A Descriptive Study in Iran.

Abstract: BACKGROUND: Coronavirus disease 2019 (COVID-19) was initially detected in Wuhan city, China. Chest CT features of COVID-19 pneumonia have been investigated mostly in China, and there is very little information available on the radiological findings occurring in other populations. In this study, we aimed to describe the characteristics of chest CT findings in confirmed cases of COVID-19 pneumonia in an Iranian population, based on a time classification. METHODS: Eighty-nine patients with COVID-19 pneumonia, confirmed by a real-time RT-PCR test, who were admitted to non-ICU wards and underwent a chest CT scan were retrospectively enrolled. Descriptive evaluation of radiologic findings was performed using a classification based on the time interval between the initiation of the symptoms and chest CT-scan. RESULTS: The median age of patients was 58.0 years, and the median time interval from the onset of symptoms to CT scan evaluation was 7 days. Most patients had bilateral (94.4%) and multifocal (91.0%) lung involvement with peripheral distribution (60.7%). Also, most patients showed involvement of all five lobes (77.5%). Ground-glass opacities (GGO) (84.3%), and mixed GGO with consolidation (80.9%) were the most common identified patterns. We also found that as the time interval between symptoms and CT scan evaluation increased, the predominant pattern changed from GGO to mixed pattern and then to elongated-containing and band-like-opacities-containing pattern; on the other hand, the percentage of lung involvement increased. CONCLUSIONS: Bilateral multifocal GGO, and mixed GGO with consolidation were the most common patterns of COVID-19 pneumonia in our study. However, these patterns might change according to the time interval from symptoms.

Autoimmune polyglandular syndrome type 3 variant in rheumatoid arthritis

Abstract: Introduction Although type 1 diabetes mellitus is largely associated with autoimmune thyroid disease and this entity has been recently referred to as autoimmune polyglandular syndrome type 3 variant, the autoimmune polyglandular syndrome type 3 variant in patients with rheumatoid arthritis has not been reported so far. We herein describe the first case of rheumatoid arthritis that was associated with autoimmune polyglandular syndrome type 3 variant. Case report A 77-year-old woman with a 15-year history of rheumatoid arthritis (RA) and a 10-year history of type 2 diabetes mellitus (T2D) presented with polyarthralgia and hyperglycaemia. Methotrexate 16 mg/week had been started from the onset and was continued, and adalimumab 40 mg/day was started for RA. Insulin treatment was also started for the diabetes. Laboratory examinations revealed high levels of C-reactive protein (CRP), rheumatoid factor, anti-cyclic citrullinated peptide antibody, and matrix metalloprotease 3. She was admitted multiple times as the symptoms recurred after treatment. Subsequently, based on the clinical course and investigations, she was diagnosed with type 1 diabetes mellitus and Graves' disease occurring during the course of RA and T2D. Her clinical course improved after reinforcement of insulin therapy and the addition of thiamazole therapy. Conclusion In patients with rheumatoid arthritis, the autoimmune polyglandular syndrome type 3 variant should be considered as the cause of the deterioration.

Antibiotics administration during last trimester of pregnancy is associated with atopic dermatitis - a cross-sectional study

Abstract: Introduction Studies regarding antibiotics administration during pregnancy and atopic dermatitis (AD) in children are only few. In this context, the objective of our study was to investigate the potential association between the timing of intrauterine exposure to antibiotics or prenatal antibiotic administration in general and AD occurrence in children. Methods This was a cross-sectional study in 1046 subjects. The exposure to antibiotics during pregnancy was initially evaluated using simple logistic regressions. Then, each period of antibiotics administration was adjusted with the other periods of antibiotics exposure (model 1) and with the other variables associated with AD in our database (model 2). Results In simple logistic regression analysis, the administration of antibiotics during pregnancy, as a whole period, presented a trend of association with AD (OR = 1.28, %CI: 0.99 - 1.65). When we analyzed antibiotic administration during each trimester of pregnancy, only antibiotherapy during the 3rd trimester was associated with AD (OR = 2.94, %CI: 1.21 - 7.12). After adjusting with all the other important risk factors associated with AD in the database, antibiotics administration during the 3rd trimester of pregnancy was still independently associated with AD (OR=2.64, %CI: 1.01 - 6.91). Conclusion Antibiotic administration during the 3rd trimester of pregnancy was independently associated with AD in children.

Four-year outcomes after percutaneous coronary intervention of unprotected left main coronary artery disease in patients with stable angina and acute coronary syndrome.

Abstract: Background. Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease (ULMCAD) have become a feasible and efficient alternative to coronary artery bypass surgery, especially in patients with acute coronary syndrome (ACS). There are limited data regarding early and late outcomes after ULMCAD PCI in patients with ACS and stable angina.The aim of this study was to compare early and four-year clinical outcomes in patients with ULMCAD PCI presenting as ACS or stable angina in a high-volume PCI center.Methods. We conducted a single center retrospective observational study, which included 146 patients with ULMCAD undergoing PCI between 2014 and 2018. Patients were divided in two groups: Group A included patients with stable angina (n = 70, 47.9%) and Group B patients with ACS (n = 76, 52.1%).Results. 30-day mortality was 8.22% overall, lower in Group A (1.43% vs 14.47%, p = 0.02). Mortality and major adverse cardiac events (MACE) rates at 4 years were significantly lower in Group A (9.64% vs 33.25%, p = 0.001, and 24.06% vs 40.11%, p = 0.012, respectively). Target lesion revascularization (TLR) at 4 year did not differ between groups (15% in Group A vs 12.76% in Group B, p = 0.5).Conclusions. In our study patients with ULMCAD and ACS undergoing PCI had higher early and long-term mortality and MACE rates compared to patients with stable angina, with similar TLR rate at 4-year follow-up.

The impact of demographic and clinical characteristics on diabetic painful neuropathy

Abstract: INTRODUCTION Diabetic neuropathy (DN) is one of the most devastating complications of diabetes mellitus; however, in contrast to other countries, there are no scientific studies in Portugal evaluating the impact of demographic and clinical characteristics of this pathological entity. The aim of this study was to evaluate the impact of gender, metabolic control, age of diabetic patients, as well as time of disease progression, the appearance of complaints related to neuropathic pain. MATERIAL AND METHODS A multicentre study with a non-probabilistic, convenience sample of 359 patients was performed employing the quantitative method, using the Statistical Package for Social Science 24 software. The p-value of p < 0.05 was defined to consider a result statistically significant. The Spearman correlation coefficient (r) was determined to determine the relationship between categorical variables. RESULTS There was no statistically significant difference in the prevalence of DN between genders (p = 0.633 and r = 0.025). There was a statistically significant relationship between the value of HbA1c and DN, with p = 0.010 and r = 0.136. There is a relationship between age and complaints of neuropathic pain, with p = 0.034 and r = 0.112. The variable, time of disease progression, is also correlated with the appearance of complaints of neuropathic pain with p = 0.020 and r = 0.112. CONCLUSION The prevalence of neuropathic pain in subjects with diabetes is not negligible and is associated with modifiable risk factors that can be identified, possibly modified and prevented. The correct approach for these patients, which involves screening and early treatment, is decisive improving functionality and quality of life.