Melioidosis and the kidney

Melioidosis, caused by the saprophytic soil and freshwater Gram‐negative aerobic bacillus Burkholderia pseudomallei, is classically characterized by pneumonia, sometimes with multiple organ abscesses, usually in patients with defined risk factors and with a mortality rate of up to 40%. It is a major cause of community‐acquired sepsis in Southeast Asia and tropical northern Australia with an expanding global geographical distribution. It is increasingly recognized as an opportunistic infectious disease of importance to physicians, who may need to suspect it in at‐risk patients that may come from or visit endemic areas, and could be fatal if treated late or inappropriately. Mortality could be prevented by early institution of specific antimicrobial therapy. Epidemiology, clinical features, overall management, and aspects of melioidosis particularly relevant to kidney disease and immunosuppression are discussed in this review.     

An Acute Multispecies Episode of Sheep‐Associated Malignant Catarrhal Fever in Captive Wild Animals in an Italian Zoo

In July 2011, in a zoological garden in Rome, Italy, malignant catarrhal fever (MCF), a fatal, systemic disease of Artiodactyla, was suspected on the basis of neurological signs and gross lesions observed in a banteng, the first animal to die of this infection. An MCF type‐specific PCR with subsequent sequencing of the PCR amplicon confirmed the aetiological agent as ovine herpesvirus‐2 (OvHV‐2). Biological samples were collected from the dead animals for gross, histological, bacteriological, virological and serological examinations. An epidemiological investigation was conducted to identify the source of the outbreak, as further deaths due to OvHV‐2 still occurred after the removal of the acknowledged reservoirs, domestic sheep and goats. For this purpose, samples from other susceptible species and reservoir hosts were collected for virological and serological analysis. In conjunction, a retrospective sero‐investigation was conducted on sera collected between 1999 and 2010 from some of the species involved in the present episode. In total, 11 animals belonging to four different species (banteng, Himalayan tahr, Nile lechwe and sika deer) died between July 2011 and October 2012. The severe gross and histological lesions were consistent with the disease, namely haemorrhages and congestion of several organs as well as lymphoid cell infiltrates and vasculitis of varying severity. The virological tests confirmed that all animals had died of sheep‐associated MCF. The investigation indicated that the OvHV‐2 infection could have been due to the arrival of sheep in the petting zoo, with cases commencing after first lambing and subsequent shedding of virus. This was also supported by the serological retrospective study that indicated limited previous MCF virus circulation. Further MCF cases that occurred even after the removal of the domestic sheep and goats were attributed to the mouflon. This episode confirms the importance of biosecurity measures in zoos, which house MCF susceptible species, especially those endangered.     

Glanders in Animals: A Review on Epidemiology,Clinical Presentation,Diagnosis and Countermeasures

Glanders or farcy, caused by Burkholderia mallei, is an infectious and zoonotic disease of solipeds. Horses, donkeys and mules are the only known natural reservoir of B. mallei. Although glanders has been eradicated from most countries, it has regained the status of a re‐emerging disease because of the numerous recent outbreaks. Pre‐symptomatic or carrier animals are the potential source of infection for the healthy equine population and play a crucial role in the spreading of the infectious agent. Glanders is characterized by ulcerating nodular lesions of the skin and mucous membrane. Generalized symptoms include fever, malaise, depression, cough, anorexia and weight loss. Burkholderia mallei can invade its host through mucous membranes, gastrointestinal tract and the integument. Its virulence mechanisms and pathogenesis are not yet completely understood. A major problem when using serological tests for diagnosing glanders is the occurrence of false‐positive and false‐negative results leading to difficulties in international trade with equids and to the spread of glanders to disease‐free regions. Moreover, poor tests critically result in poor control of disease. These tests are not only incapable of discriminating between B. mallei and B. pseudomallei antibodies, they are also unable to differentiate between malleinized and naturally infected animals. Combined use of both serological and molecular detection methods increases the detection rate of glanders. Countermeasures against glanders include early detection of disease in susceptible animals, stringent quarantine measures, testing and safe destruction of infected carcasses, adequate compensation to the animal owners, disinfection of infected premises and awareness about glanders and the zoonotic implications through veterinary extension services. An account of the clinical picture and successful experimental therapy of spontaneous equine glanders is also given.     

Nationwide Cross‐Sectional Study on Bovine Tuberculosis by Intra Vitam Testing in Germany, 2013–2014

Germany was declared officially free from bovine tuberculosis (bTB) effective from 1 July 1996. After the occurrence of several Mycobacterium (M.) bovis outbreaks in north‐western Germany in recent years with high intraherd prevalence at the time of detection, the reliability of abattoir surveillance as the principal component of the national bTB control programme was debated by veterinary public health officials. Rising numbers of wildlife‐associated outbreaks caused by M. caprae in southern Germany eventually prompted a nationwide cross‐sectional study on bTB. A total of 51 999 cattle, that is 0.41% of the national herd kept on 1.73% of German cattle farms, were tested. Despite 4 positive and 152 inconclusive single intradermal comparative cervical test results, none of the animals was confirmed as bTB‐positive by a subsequent interferon‐release assay or by post‐mortem PCR testing. The estimated prevalence of bTB in Germany was thus calculated as 0.0% (CI 0.0000–0.0064%) affirming that Germany still qualifies as an officially tuberculosis‐free (OTF) country. Occasional randomized nationwide testing can be an appropriate tool to reassure the OTF status and may also help to maintain an appropriate training level for the diagnostic procedures and for supporting sustained disease awareness among stakeholders.     

Effects of Ureteral Stent on Urologic Complications in Renal Transplant Recipients: A Retrospective Study

The aim of the present study was to analyze the effects of ureteral stents used in renal transplantation on urologic as well as other complications. Cases of renal transplants from living or deceased donors performed in our hospital were retrospectively evaluated. The effects of the routine use of ureteral stents on postoperative complications were investigated. All outcomes and complications encountered during the postoperative follow-up were recorded. The Lich-Gregoire technique, which is a method of extravesical ureteroneocystostomy, was performed on all patients. One hundred and twenty-two patients underwent renal transplantation between 2001 and 2007 in our hospital. Stents were placed routinely in all patients. Leakage was observed in one patient, and one patient developed an obstruction; however, none of the patients developed an infection. A lymphocele developed in one patient. All urologic complications were treated without major morbidity. Graft loss did not occur. Complications following urinary anastomosis have a high rate of morbidity in renal transplantation. Ureteral stenting in renal transplant recipients prevents early urologic complications. The data generated in the current study were compared to the literature.     

A Retrospective Study on the Influence of Apolipoprotein E and Serum Lipids in Progressive Renal Failure

Background: Progression of renal failure is associated with altered lipoprotein metabolism. Apolipoprotein E polymorphism is an important genetic marker for dyslipidemia. The main purpose of this retrospective study was to examine the influence of apolipoprotein E polymorphism and serum lipids level on the progression rate in a group of patients with kidney diseases of diverse etiology. Methods: Progression rate, with regard to apolipoprotein E polymorphism and initial serum creatinine value, median (162 μmol/l), was determined by reviewing the charts of 385 patients on renal replacement therapy with a median follow-up time of 4.85 years. Results: Progression rate was negatively correlated to serum cholesterol in the group with type 2 diabetes (p= 0.001). In addition, the urine albumin excretion rate (UAER) was higher in type 2 diabetics carrying the ɛ2 allele (2.1 g/l) as compared to non-ɛ2 allele carriers (1.2 g/l) (p=0.009). Although serum cholesterol in patients with autosomal dominant polycystic kidney disease (ADPKD) carrying the apolipoprotein ɛ4 allele was 5.87 ± 1.0 mmol/l, which was significantly higher compared to non-ɛ4 carriers, 4.97 ± 1.1 mmol/l (p=0.026), progression rate was similar in the two groups, 4.4 ± 0.8 μmol/l/year. An increase in the relative frequency of the apolipoprotein ɛ4 allele was found in patients with ADPKD (0.29), as compared to (0.16) in the rest of the diagnostic groups (p=0.0023). In addition, in the whole study population a positive correlation was found between progression rate and underlying disease (p < 0.005), UAER (p < 0.005) and blood pressure (p < 0.005). Conclusions: The results of the present study indicate that the decline of renal function in patients with diabetes type 2 may not be associated with levels of plasma cholesterol, but with triglyceride lipoproteins, considered remnant lipoproteins. Any association between cholesterol and apolipoprotein ɛ4 allele with progression in ADPKD may not necessarily be straightforward since this disease is influenced by other genetic and unidentified factors.     

Breast Cancer in the Elderly: Retrospective Study on Diagnosis and Treatment According to National Guidelines

Abstract:  We set out to investigate the level of accordance of diagnosis and treatment of elderly breast cancer patients with national guidelines and to study predictors of deviation. Data on patient and tumor variables were collected from charts of 166 patients aged 70 years and older, diagnosed at our hospital in 2002–2004. Diagnostic work-up and treatment were compared with guidelines and reasons for deviation were recorded; 122 (74%) patients were diagnosed and treated in accordance with guidelines. Diagnosis was incomplete in 19 patients (11%). Surgery, radiotherapy, and hormonal therapy were withheld in 19 (11%), 11 (7%), and 9 (5%) patients, respectively. Guideline deviation was motivated in 18 patients (11%) (comorbidity n  = 11, patients' preferences n  = 5, age n  = 2), unmotivated in 18 (11%), and undeliberate in 8 (5%). Our study demonstrates that deviation from guidelines in elderly breast cancer patients mainly occurs due to a deliberate adjustment to patient's comorbidity and preference.     

The Effect of Cardiopulmonary Bypass and Hypothermic Circulatory Arrest on Hepatic Histology in Newborn Animals: An Experimental Study

Still little is known about the effect of cardiac surgery on neonatal hepatic tissue. We examined the effect of cardiopulmonary bypass (CPB) and the effect of deep hypothermic circulatory arrest (DHCA) on neonatal hepatic tissue. Liver biopsies of neonatal piglets were taken after CPB (n = 4), after DHCA (n = 5), and after surgery without CPB (non‐CPB; n = 3). Additionally, findings were compared to those of control piglets (n = 9). The liver specimens were fixed, stained with hematoxylin and eosin, and scored regarding inflammatory reaction, hepatocellular edema, and apoptosis. Inflammation score of treated groups was higher than in control; CPB 2.5 ± 0.5, DHCA 1.6 ± 0.4, non‐CPB 1.2 ± 0.6, control 0.4 ± 0.3 (P < 0.001 CPB and DHCA vs. control; P < 0.05 non‐CPB vs. control). Hepatic cell edema was more evident after DHCA (score 2.0 ± 0.4 vs. 0.2 ± 0.3 in control and 0.6 ± 0.5 after CPB; P < 0.001 and P < 0.05, respectively). The highest apoptotic cell count was in the non‐CPB group (22.3 ± 6.3 vs. 11.4 ± 3.6 in control and 8.9 ± 5.4 after CPB; P < 0.05). The present study showed that (i) surgical trauma induces hepatic cell apoptosis; (ii) CPB increases hepatic inflammatory reaction; and (iii) DHCA amplifies hepatic cell edema.     

A Retrospective Study on the Use of a Low-Molecular-Weight Heparin for Thromboembolism Prophylaxis in Large-Volume Liposuction and Body Contouring Procedures

This retrospective study was designed to evaluate the efficacy of low-molecular-weight heparin (enoxeparin) as a prophylaxis for venous thromboembolism and deep venous thrombosis (DVT) in the management of large-volume liposuction, added body-contouring procedures, or both. The author present an 18-month experience with the use of this therapy for 291 consecutive patients. All the patients fell into the categories of high risk and highest risk for the development of deep vein thrombosis, embolism, or both. Three patients experienced transient DVT-like symptoms and underwent a thorough workup by an independent highly specialized critical care medical team. The results were found ultimately to be inconclusive for DVT and pulmonary embolism. However, all the patients experienced a complete recovery. The results show a 0% incidence of DVT and pulmonary embolism among patients who received enoxeparin as prophylaxis. The medication did not precipitate major bleeding when administered 1 h after surgery. This study offers the first report that describes the use of enoxeparin in aesthetic surgery for high-risk patients. The authors feel the need to inform their colleagues of the benefits obtained over the past 18 months by incorporating this therapy in large-volume liposuction and extensive body-contouring procedures performed during the same operative session. This study was conducted by a highly experienced surgical team in a fully accredited outpatient facility with established protocols for handling these types of procedures on a daily basis. The authors are optimistic about the results, and the use of enoxeparin is now part of their postoperative regimen in high-risk aesthetic surgery cases.     

Denosumab联合手术治疗桡骨骨巨细胞瘤——外科降级及预后

目的 桡骨是骨巨细胞瘤好发部位,囊内刮除术后复发率高,广泛切除术后功能欠佳。本研究旨在评估Denosumab治疗桡骨GCT的疗效和安全性,分析Denosumab对手术方式及预后的影响。 方法 2014年1月-2016年4月,7例复杂难治桡骨GCT患者在围手术期接受Denosumab治疗。比较应用Denosumab后手术方案的差异,监测用药过程中的副反应。随访患者的肿瘤学预后、术后功能。 结果 平均年龄28.43岁（23-33岁,中位年龄29岁）,男性4例,女性3例。所有患者均有明确骨巨细胞瘤病理诊断, 2例为初次手术后复发。以手术结束为随访开始时间,末次随访时间为2017年12月。随访时间20-41个月（平均26.71个月）。用药期间无死亡病例,患者均按计划用药,用药总次数4-10次（平均7.71次）。未见下颌骨坏死。血钙、碱性磷酸酶、肝肾功能、血色素、白细胞、血小板等实验室指标未见异常。85.71 %（6/7）的病人外科手术降级（行囊内刮除术5例,瘤段广泛切除2例）,7例患者随访期内均未见肿瘤复发。患者术后MSTS功能评分平均27.86（92.87%）,DASH评分7.43,VAS评分1分。 结论 Denosumab是治疗桡骨骨巨细胞瘤的有效手段,围手术期用药可降低手术难度,从而实现外科降级并降低复发风险。