Effect of pulmonary hypertension on outcome of pulmonary tuberculosis

BackgroundThis study performed at the National Research Institute of Tuberculosis and Lung Disease, Tehran, Iran, aimed to evaluate the effect of concomitant pulmonary hypertension on the outcome of pulmonary tuberculosis.MethodsNew cases of pulmonary tuberculosis were recruited for the study. Pulmonary hypertension was defined as systolic pulmonary arterial pressure ≥35 mm Hg estimated by transthoracic Doppler echocardiography. We assessed the relationship between pulmonary hypertension and mortality during the six-month treatment of tuberculosis.ResultsOf 777 new cases of pulmonary tuberculosis, 74 (9.5%) had systolic pulmonary arterial pressure ≥35 mm Hg. Ten of them (13.5%) died during treatment compared to 5% of cases with pulmonary arterial pressure less than 35 mm Hg (p = 0.007). Logistic regression analysis showed that pulmonary hypertension and drug abuse remained independently associated with mortality (OR = 3.1; 95% CI: 1.44–6.75 and OR = 4.4; 95% CI: 2.35–8.17, respectively).ConclusionA significant association was found between mortality and presence of pulmonary hypertension and drug abuse among new cases of pulmonary tuberculosis.     

Clinical impact of rapid viral respiratory panel testing on pediatric critical care of patients with acute lower respiratory infection

BackgroundWe aimed to determine the impact of utilizing a rapid panel test of respiratory viral and atypical bacteria (FilmArray® Respiratory Panel, FA RP) on etiological diagnosis of acute lower respiratory infection (ALRI) and antimicrobial stewardship in critical care pediatric patients.MethodsProspective cohort study of patients aged < 18 years with clinical diagnosis of ALRI that were admitted to the Pediatric Intensive Care Unit (PICU) of Hospital Sant Joan de Deu (Barcelona, Spain) during December 2015–February 2017. Patients were diagnosed by FA RP and by a bundle of routine microbiological assays.ResultsALRI viral and bacterial etiology was confirmed by a composite reference standard of routine microbiological assays in 72 (55.4%) and 15 (11.5%) respiratory samples, respectively, that were collected from 130 children (median age, 3.5 months, IQR 1.1–14.8 months; 54.6% male). Comparatively, FA RP use increased etiological confirmation of ALRI in up to 123 (94.6%) samples (p < 0.001) but only determined a bacterial origin in 2 (1.5%). Availability of diagnostic results before patient discharge from the PICU rose from 65.4 to 38.5% (p < 0.001). Use of the new panel test directly influenced antimicrobial stewardship in 11 (8.4%) episodes, leading to discontinuation of antiviral drugs (n = 5), administration of targeted antibiotics (n = 3), antiviral therapy start (n = 2) and both targeted antibiotic administration and discontinuation of antiviral drugs (n = 1).ConclusionFA RP contributed to improve etiological diagnosis of ALRI in a timely manner while enhancing a more rational use of antimicrobial drugs in critical care pediatric patients.     

Development of knowledge-based clinical decision support system for patients included in colorectal screening program

Background & aimsColorectal (CRC) screening programs represent a large volume of procedures that need a follow-up endoscopy. A knowledge-based clinical decision support system (K-CDSS) is a technology which contains clinical rules and associations of compiled data that assist with clinical decision-making tasks. We develop a K-CDSS for management of patients included in CRC screening and surveillance of colorectal polyps.MethodsWe collected information on 48 variables from hospital colonoscopy records. Using DILEMMA Solutions Platform © (https://www.dilemasolution.com) we designed a prototype K-CDSS (PoliCare CDSS), to provide tailored recommendations by combining patients data and current guidelines recommendations. The accuracy of rules was verified using four scenarios (normal colonoscopy, lesions different than polyps, non-advanced adenomas and advanced adenomas). We studied the degree of agreement between the clinical assessments made by expert doctors and nurses equipped with PoliCare CDSS. Two experts confirmed a correlation between guidelines and PoliCare recommendations.Results56 consecutive endoscopy cases from colorectal screening program were included (62.8 years; range 53-71). Colonoscopy results were: absence of colon lesions (n = 7, 12.5%), lesions in the colon that are not polyps (n = 3, 5.4%) and resected colonic polyps (n = 46, 82.1%; 100% R0 resection). Patients with resected polyps presented non-advanced adenoma (n = 21, 45.6%) or advanced lesions (n = 25, 54.4%). There were no differences in erroneous orders with PoliCare CDSS (Kappa value 1.0).ConclusionsPoliCare CDSS can easily be integrated into the workflow for improving the overall efficiency and better adherence to evidence-based guidelines.     

Survival of HIV patients with tuberculosis started on simultaneous or deferred HAART in the THRio cohort,Rio de Janeiro,Brazil

BackgroundThe timing of highly active antiretroviral therapy (HAART) after a tuberculosis diagnosis in HIV-infected patients can affect clinical outcomes and survival. We compared survival after tuberculosis diagnosis in HIV-infected adults who initiated HAART and tuberculosis therapy simultaneously to those who delayed the start of HAART for at least two months.MethodsThe THRio cohort includes 17,983 patients receiving HIV care in 29 public clinics in Rio de Janeiro, Brazil. HAART-naïve patients at the time of a new TB diagnosis between September 2003 and June 2008 were included. Survival was measured in days from diagnosis of TB. We compared survival among patients who initiated HAART within 60 days of TB treatment (simultaneous – ST) to those who started HAART >60 days of TB treatment or never started (deferred – DT). Kaplan–Meier plots and Cox proportional hazards regression analyses were conducted.ResultsOf 947 patients diagnosed with TB, 572 (60%) were HAART naïve at the time of TB diagnosis; 135 were excluded because of missing CD4 count results. Among the remaining 437 TB patients, 56 (13%) died during follow-up: 25 (10%) among ST patients and 31 (16%) in DT group (p = 0.08). ST patients had lower median CD4 counts at TB diagnosis than DT patients (106 vs. 278, p < 0.001). Cox proportional hazards utilizing propensity score analysis showed that DT patients were more likely to die (adjusted HR = 1.89; 95% CI: 1.05–3.40; p = 0.03).ConclusionHAART administered simultaneously with TB therapy was associated with improved survival after TB diagnosis. HAART should be given to patients with HIV-related TB as soon as clinically feasible.     

Association between toll-like receptor2 Arg677Trp and 597T/C gene polymorphisms and pulmonary tuberculosis in Zahedan,Southeast Iran

BackgroundIt is well known that toll-like receptor 2 (TLR2) mediates responses of both innate and adaptive immunity to microbial pathogen, including mycobacteria. Single-nucleotide polymorphisms (SNPs) in the TLR2 gene that impair its function may be associated with the development of pulmonary tuberculosis (PTB). The aim of this study was to evaluate the possible association between TLR2 Arg677Trp and 597T/C polymorphisms and PTB in a sample of Iranian population.Materials and methodsThis case–control study was performed on 174 PTB and 177 healthy subjects. Tetra amplification refractory mutation system-polymerase chain reaction (T-ARMS-PCR) was used to detect the SNPs.ResultsThere was no significant difference in the polymorphism of Arg677Trp of the TLR2 gene among PTB and control groups (p > 0.05). The results showed that there was a significant difference between case and control groups regarding 597T/C polymorphism (χ² = 12.21, p = 0.002). The TC and CC genotypes were found to be associated with the risk of PTB (OR = 2.13, 95% CI = 1.25–3.62, p = 0.005 and OR = 4.88, 95% CI = 1.56–15.26, p = 0.007, respectively).ConclusionOur data suggest that 597T/C polymorphism, but not Arg677Trp polymorphism, of the TLR-2 gene is a risk factor for susceptibility to PTB in a sample of Iranian population.     

The impact of diabetics and smoking on gender differences of smear positive pulmonary tuberculosis incidence

BackgroundSeveral determinants are responsible for different incidences of smear positive pulmonary tuberculosis (TB). The main determinants are cigarette smoking and diabetes mellitus. The aim of this study is to determine the effect of these risk factors effect modifiers in TB/gender association.MethodologyIn this retrospective cohort, relative risk of gender in developing smear positive TB as well as its interaction with smoking and diabetes mellitus were investigated.ResultsOf 1243 smear positive TB cases, 63.2% were male. Prevalences of diabetes mellitus among men and women TB cases were 9.2% and 22.9% respectively (p < 0.001). Frequency of cigarette smoking among men was significantly higher than that in women (61.7% vs. 7.6% respectively, p < 0.001). Male gender, increased the risk of developing smear positive TB as of 98% and 5% in smokers and non-smokers respectively (p = 0.001), indicating an interaction between gender and smoking in the effect on TB. In addition, male gender increased the risk of TB as of 13% and 34% in patients with and without diabetes mellitus respectively (p = 0.300) indicating no interaction between gender and diabetes mellitus on TB incidence.ConclusionOur study showed that cigarette smoking is a determinant factor for gender differences in TB incidence but diabetes mellitus does not affect the association between TB and gender.     

Causes of secondary hypertension in the young population: A monocentric study

ObjectiveTo study the prevalence of different causes of hypertension in young adults referred to a hypertension center in the south west of France.MethodsWe conducted a retrospective overview of patients younger than 40 years old hospitalized consecutively in the Hypertension department of Toulouse University Hospital between 2012 and 2014. Clinical data about gender, age, anthropomorphic parameters and blood pressure measurement by 24 h Ambulatory Blood Pressure Monitoring (ABPM) were recorded. Biological data concerned dosages of kalemia, renin and aldosterone in the supine or after 15 min of seating. Recorded radiological examinations were renal artery ultrasound and abdominal CT scan.ResultsOne hundred and forty-eight detailed medical records were analyzed, 69 women and 79 men. Among the 69 women, the causes of secondary hypertension were primary aldosteronism (n = 7), fibromuscular dysplasia (n = 5) and renal disease (n = 4). Oral contraceptives were involved in 13 women. In addition, essential hypertension concerned 40 women (58%). Among the 79 men, the causes of secondary hypertension were primary aldosteronism (n = 10), fibromuscular dysplasia (n = 3), left main renal artery entrapment by a diaphragmatic crura (n = 2), renal disease (n = 1), pheochromocytoma (n = 3) and coarctation of the aorta (n = 2). In addition, essential hypertension concerned 58 men (73%).ConclusionsIn our population, the prevalence of secondary hypertension is close to 33% (42% of females and 27% of males), with the following main causes: primary aldosteronism for 11.5%; fibromuscular dysplasia for 5.4%. Oral contraceptives were involved in the hypertension of 19% of the females.     

Colonoscopic perforations in inflammatory bowel disease: A retrospective study in a French referral centre

BackgroundWhether inflammatory bowel disease patients are at increased risk of colonoscopic perforations remains controversial. Aim of this study was to investigate whether these patients are at increased risk of perforations.MethodsElectronic charts of all patients enrolled in the Nancy IBD cohort (1999–2012) were reviewed. All non-inflammatory bowel disease patients who underwent colonoscopy (1999–2012) were used as controls.ResultsOf 17,992 colonoscopies, 2375 (13.2%) were performed for inflammatory bowel disease: 1547 for Crohn's disease and 828 for ulcerative colitis. Four IBD patients (0.168%) experienced perforation. Perforation occurred in the sigmoid colon (n = 3) and right colon (n = 1) during disease monitoring or colonic stenosis dilatation. Three patients underwent surgery (2 stomas and no death). Colonoscopic perforation occurred in 16/15,617 controls (0.102%): colonic cancer diagnosis (n = 5, 31.3%) or dilatation (n = 2, 12.5%), polypectomy (n = 5, 31.3%) or mucosectomy (n = 1, 6.3%), and follow-up after diverticulitis (n = 2, 12.5%). Perforation rate was not different between IBD and controls (p = 0.57). Perforations occurred in the sigmoid colon (n = 10, 62.5%), the right colon (n = 4, 25%) and the rectum (n = 2, 12.5%). Twelve controls underwent surgery (9 stomas and one death).ConclusionIn this referral centre-based cohort, inflammatory bowel disease patients were not at increased risk of colonoscopic perforation compared to non-IBD controls.     

Diagnostic accuracy of red blood cell distribution width to platelet ratio for predicting liver fibrosis in patients with chronic hepatitis B: A meta-analysis

ObjectiveThis study aims to systematically review the performance of red blood cell distribution width to platelet ratio (RPR) in the diagnosis of significant or advanced fibrosis, and cirrhosis associated with hepatitis B virus (HBV).MethodsThe relevant studies were comprehensively searched in English databases such as Web of Science, PubMed, EMBASE, Cochrane Library, as well as Chinese databases such as China National Knowledge Infrastructure, Wanfang Data from the inception to March 2021. Accuracy of RPR in diagnosing significant or advanced fibrosis and liver cirrhosis was assessed by area under the curve (AUC), pooled sensitivity and specificity, as well as positive and negative likelihood ratios. Stata 15.0 software was applied to analyze the data.ResultsIn total, 13 literature met the requirements, including patients with significant fibrosis (n = 1890), advanced fibrosis (n = 645), and cirrhosis (n = 499). The prevalence rates of significant fibrosis, advanced fibrosis and cirrhosis were 49.31% (range: 17.25–84.21%), 37.07% (range: 9.60–58.20%) and 2.18% (range: 2.78–44.19%), respectively. The AUCs for predicting significant fibrosis, advanced fibrosis, and cirrhosis by RPR were 0.73 (95%CI: 0.69–0.76), 0.80 (95%CI: 0.77–0.84) and 0.80 (95%CI: 0.76–0.83), respectively.ConclusionRPR is of some diagnostic value to the prediction of HBV-related significant fibrosis, advanced fibrosis and cirrhosis. This conclusion is urgently needed to be verified by further multi-center studies of large sample size and rigorous design.     

Central nervous system infection following allogeneic hematopoietic stem cell transplantation

Objective/backgroundHere, we described the clinical characteristics and outcomes of central nervous system (CNS) infections occurring after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in a single institution over the previous 6 years.MethodsCharts of 353 consecutive allogeneic transplant recipients were retrospectively reviewed for CNS infection.ResultsA total of 17 cases of CNS infection were identified at a median of 38 days (range, 10–1028 days) after allo-HSCT. Causative pathogens were human herpesvirus-6 (n = 6), enterococcus (n = 2), staphylococcus (n = 2), streptococcus (n = 2), varicella zoster virus (n = 1), cytomegalovirus (n = 1), John Cunningham virus (n = 1), adenovirus (n = 1), and Toxoplasma gondii (n = 1). The cumulative incidence of CNS infection was 4.1% at 1 year and 5.5% at 5 years.ConclusionMultivariate analysis revealed that high-risk disease status was a risk factor for developing CNS infection (p = .02), and that overall survival at 3 years after allo-HSCT was 33% in patients with CNS infection and 53% in those without CNS infection (p = .04).     

Acute variceal haemorrhage in the United Kingdom: Patient characteristics,management and outcomes in a nationwide audit

BackgroundDespite advances in treatment, acute variceal haemorrhage remains life-threatening.AimTo describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality.MethodsMulti-centre clinical audit conducted in 212 UK hospitals.ResultsIn 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24 h with 64% (n = 339) receiving endoscopic therapy. Prior to endoscopy, 57% (n = 299) received proton pump inhibitors, 44% (n = 232) vasopressors and 27% (n = 144) antibiotics. 73% (n = 386) received red cell transfusion, 35% (n = 184) fresh frozen plasma and 14% (n = 76) platelets, with widely varying transfusion thresholds. 26% (n = 135) experienced further bleeding and 15% (n = 80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve = 0.74, P < 0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22–4.07, P = 0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29–7.26, P = 0.01).ConclusionsAlthough mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.     

Lung ultrasound in internal medicine: A bedside help to increase accuracy in the diagnosis of dyspnea

BackgroundDyspnea is one of the most frequent causes of admission in Internal Medicine wards, leading to a sizeable utilization of medical resources.Study design and methodsThe role of bedside lung ultrasound (LUS) was evaluated in 130 consecutive patients (age: 81 ± 9 years), in whom blindly collected LUS results were compared with data obtained by clinical examination, medical history, blood analysis, and chest X-ray. Dyspnea etiology was classified as “cardiac” (n = 80), “respiratory” (n = 36) or “mixed” (n = 14), according to the discharge diagnosis (congestive heart failure either alone [n = 80] or associated with pneumonia [n = 14], pneumonia [n = 24], and obstructive disventilatory syndrome [n = 12]). An 8-window LUS protocol was applied to evaluate B-line distribution, “interstitial syndrome” pattern, pleural effusion and images of static or dynamic air bronchogram/focal parenchymal consolidation.ResultsThe presence of a generalized “interstitial syndrome” at the initial LUS evaluation allowed to discriminate “cardiac” from “pulmonary” Dyspnea with high sensitivity (93.75%; confidence intervals: 86.01%–97.94%) and specificity (86.11%; 70.50%–95.33%). Positive and negative predictive values were 93.76% (86.03%–97.94%) and 86.09% (70.47%–95.32%), respectively. Moreover, LUS diagnostic accuracy for the diagnosis of pneumonia was not inferior to that of chest X-ray.ConclusionsBedside LUS evaluation contributes with high sensitivity and specificity to the differential diagnosis of Dyspnea. This holds true not only in the emergency setting, but also in the sub-acute Internal Medicine arena. A wider use of this portable technique in our wards is warranted.     

Similar prevalence,different spectrum: IgE-mediated food allergy among Turkish adolescents

BackgroundScarcity of reliable data on food allergy prevalence exists in Turkey. We aimed to assess reported and confirmed IgE-mediated food allergy prevalence, and define the spectrum of allergenic food.MethodsWe prospectively evaluated the ISAAC Phase II study population for food allergy. Participants that reported experiencing food allergy symptom in the last year and/or were skin prick test positive for a predefined list of food allergens, were interviewed via telephone, and those considered as having food allergy were invited to undergo clinical investigation, including challenge tests.ResultsA total of 6963 questionnaires were available. Parental reported food allergy prevalence and skin prick sensitisation rate were 20.2 ± 0.9% and 5.9 ± 0.6%. According to the above-defined criteria, 1162 children (symptom positive n = 909, skin prick test positive n = 301, both positive n = 48) were selected and 813 (70.0%) were interviewed via telephone. Out of 152 adolescents reporting a current complaint, 87 accepted clinical investigation. There were 12 food allergies diagnosed in nine adolescents, with food allergy prevalence of 0.16 ± 0.11%. The most common foods involved in allergic reactions were walnut (n = 3) and beef meat (n = 2), followed by hen's egg (n = 1), peanut (n = 1), spinach (n = 1), kiwi (n = 1), cheese (n = 1), hazelnut (n = 1) and peach (n = 1).ConclusionsWhile parental reported food allergy prevalence was within the range reported previously, confirmed IgE-mediated food allergy prevalence among adolescents was at least 0.16%, and the spectrum of foods involved in allergy differed from Western countries, implying environmental factors may play a role.     

Effect of cilostazol on arteriovenous fistula in hemodialysis patients

BackgroundThe maturation and patency of permanent vascular access are critical in patients requiring hemodialysis. Although numerus trials have been attempted to achieve permanently patent vascular access, little have been noticeable. Cilostazol, a phosphodiesterase-3 inhibitor, has been shown to be effective in peripheral arterial disease including vascular injury-induced intimal hyperplasia. We therefore aimed to determine the effect of cilostazol on the patency and maturation of permanent vascular access.MethodsThis single-center, retrospective study included 194 patients who underwent arteriovenous fistula surgery to compare vascular complications between the cilostazol (n = 107) and control (n = 87) groups.ResultsThe rate of vascular complications was lower in the cilostazol group than in the control group (36.4% vs. 51.7%; p = 0.033), including maturation failure (2.8% vs. 11.5%; p = 0.016). The rate of reoperation due to vascular injury after hemodialysis initiation following fistula maturation was also significantly lower in the cilostazol group than in the control group (7.5% vs. 28.7%; p < 0.001). However, there were no significant differences in the requirement for percutaneous transluminal angioplasty (PTA), rate of PTA, and the interval from arteriovenous fistula surgery to PTA between the cilostazol and control groups.ConclusionCilostazol might be beneficial for the maturation of permanent vascular access in patients requiring hemodialysis.     

Evaluation of prophylactic antibiotic regimens on recurrence and mortality in spontaneous bacterial peritonitis

Introduction and objectivesLimited data describe current SBP epidemiology and specific secondary SBP prophylactic regimens, leading to variable prescribing practices. This work aims to compare 90-day and one-year SBP recurrence and mortality based on secondary SBP antibiotic prophylaxis regimens.Materials and methodsWe performed a retrospective cohort of patients >18 years with an SBP diagnosis from 2010 to 2015 at two academic institutions. Eligible patients had ascitic PMN counts ≥250 cells/mm³ or a positive ascitic culture. Patients were compared based on secondary SBP prophylaxis regimens (i.e., daily, intermittent, or no prophylaxis).ResultsOf 791 patients with ascitic fluid samples, 86 patients were included. Antibiotic prophylaxis included daily (n = 34), intermittent (n = 36), or no prophylaxis (n = 16). Nearly half of SBP episodes had a positive ascitic fluid culture; 50% were gram-negative pathogens, and 50% were gram-positive pathogens. Daily and intermittent regimens had similar rates of recurrence at 90-days (19.4% vs. 14.7%, p = 0.60) and one-year (33.3% vs. 26.5%, p = 0.53). Similarly, mortality did not differ among daily and intermittent regimens at 90-days (32.4% vs. 30.6%, p = 0.87) or one-year (67.6% vs. 63.9%, p = 0.74). When comparing any prophylaxis vs. no prophylaxis, there were no differences in 90-day or one-year recurrence or mortality.ConclusionsIn patients with a history of SBP, our data indicate similar outcomes with daily, intermittent, or no secondary antibiotic prophylaxis. With available data, including ours, demonstrating a changing epidemiology for SBP pathogens, further data is required to determine if traditional approaches to secondary SBP prophylaxis remain appropriate.     

Study of the relationship between human MIF level,MIF-794CATT5-8 microsatellite polymorphism,and susceptibility of tuberculosis in Southwest China

ObjectiveTo study the human migration inhibitory factor (MIF) level in tuberculosis (TB) patients, and the relationship between MIF-794CATT microsatellite polymorphism and susceptibility of TB in Southwest China.MethodsTB patients (n = 151) and healthy unrelated controls (n = 149) were recruited for this study. Genomic DNA was extracted, and then amplified by polymerase chain reaction (PCR). MIF-794CATT_5-8 microsatellite polymorphism was genotyped by DNA sequencing. MIF level was detected by ELISA.ResultsIn the TB group, the repeat number of 7/7 and 7/8 (17.89%) was significantly higher than that of the control group (8.05%), and the serum MIF level was also much higher than that of the healthy controls (705.21 ± 67.98 vs. 355.31 ± 57.29 pg/mL, p < 0.01).ConclusionThe appearance of MIF-794CATT 7/7 and 7/8 is associated with susceptibility to TB, and may play an important role in the occurrence and development of TB in Southwest China.     

Pegvisomant treatment in acromegaly in clinical practice: Final results of the French ACROSTUDY (312 patients)

ObjectiveWe report the final analysis of the French ACROSTUDY, using data revised and enriched since the 2013 interim analysis. Our objective was to validate the use of pegvisomant (PEGV) in the treatment of acromegaly and to determine efficacy and safety.Patients and methodsPatients with acromegaly treated with PEGV and followed up for at least 5 years were included. Eighty-eight investigators from 62 clinical centers in France included patients from April 2007 to April 2014. PEGV dose and administration frequency were determined by the physicians, based on their clinical evaluation and local habits. No additional examinations beyond those performed in normal follow-up were required. Minimum recommended follow-up included check-ups at treatment initiation, 6 months, 12 months and then annually.ResultsIn total, 312 patients were enrolled. Mean age was 46.1 ± 14.3 years at introduction of PEGV. Median PEGV treatment duration was 6.3 years and median follow-up was 5.6 years. Median dose at initiation was 10 mg/day. The percentages of patients with IGF-1 ≤ ULN (upper limit of normal) were 10% (n = 300) at baseline, 54% at 6 months (n = 278), and 61.7% (n = 253) at 2 years, then stabilizing at 64.4% (n = 180) at 5 years. Mean PEGV dose was 17.4 ± 11.7 mg in patients with controlled disease versus 21.1 ± 17.3 mg in those without control at 5 years. At 5 years, 21.8% of patients (54/248) were receiving >30 mg PEGV per day. In patients with at least one pituitary imaging procedure during the 5-year follow-up (n = 292), the most recent image showed stable tumor volume in 212 subjects (72.6%), increased volume in 13 (4.5%), and decreased volume in 30 (10.3%). No PEGV treatments were permanently discontinued due to transaminase elevation. There were no cases of liver failure.ConclusionThe French ACROSTUDY showed normalization of IGF-1 levels in 64.4% of a real-life cohort of patients, mostly with uncontrolled disease despite multiple prior therapies. Long-term follow-up showed a sustained effectiveness and good long-term safety.     

Patterns of Physical Activity Progression in Patients With COPD

IntroductionAlthough mean physical activity in COPD patients declines by 400–500 steps/day annually, it is unknown whether the natural progression is the same for all patients. We aimed to identify distinct physical activity progression patterns using a hypothesis-free approach and to assess their determinants.MethodsWe pooled data from two cohorts (usual care arm of Urban Training [NCT01897298] and PROactive initial validation [NCT01388218] studies) measuring physical activity at baseline and 12 months (Dynaport MoveMonitor). We identified clusters (patterns) of physical activity progression (based on levels and changes of steps/day) using k-means, and compared baseline sociodemographic, interpersonal, environmental, clinical and psychological characteristics across patterns.ResultsIn 291 COPD patients (mean ± SD 68 ± 8 years, 81% male, FEV₁ 59 ± 19%_pred) we identified three distinct physical activity progression patterns: Inactive (n = 173 [59%], baseline: 4621 ± 1757 steps/day, 12-month change (Δ): −487 ± 1201 steps/day), Active Improvers (n = 49 [17%], baseline: 7727 ± 3275 steps/day, Δ: + 3378 ± 2203 steps/day) and Active Decliners (n = 69 [24%], baseline: 11 267 ± 3009 steps/day, Δ: −2217 ± 2085 steps/day). After adjustment in a mixed multinomial logistic regression model using Active Decliners as reference pattern, a lower 6-min walking distance (RRR [95% CI] 0.94 [0.90–0.98] per 10 m, P = .001) and a higher mMRC dyspnea score (1.71 [1.12–2.60] per 1 point, P = .012) were independently related with being Inactive. No baseline variable was independently associated with being an Active Improver.ConclusionsThe natural progression in physical activity over time in COPD patients is heterogeneous. While Inactive patients relate to worse scores for clinical COPD characteristics, Active Improvers and Decliners cannot be predicted at baseline.     

A survey of knowledge,attitudes, and practices relating to musculoskeletal examination among pediatricians in Maharashtra,India

AimsTo explore knowledge, attitudes, and practices relating to musculoskeletal examination (MSKe) in one state of India.MethodsPediatricians from the state of Maharashtra (capital – Mumbai) were invited to complete an 11-item web-based survey. Participation implied consent and the survey was based on a similar UK study. All pediatricians from the state of Maharashtra (n = 1523) were invited to participate; 223 pediatricians responded (response rate: 14.64%) with variable training in pediatrics and experience.ResultsRespondents reported similar time devoted within their consultations to management plan, history, and physical examination. Most (n = 166, 74.44%) had been taught to examine the musculoskeletal system in children (n = 82, 36.77%) or in both adults and children (n = 84, 37.67%). However, MSKe was not part of their current routine practice, despite many (n = 115, 51.57%) deeming this an important part of assessment. The majority (n = 207, 92.82%) were very confident (n = 7, 3.14%), or confident in some (n = 120, 53.81%) or most (n = 80, 35.87%) aspects of performing a structured MSKe, but were less confident with MSKe compared to other systems. Most (n = 158, 70.85%) were unaware of pGALS (Pediatric Gait Arms Legs Spine) prior to the survey but many (n = 204, 91.48%) were supportive of its inclusion within the curriculum for undergraduates and/or postgraduates, and expressed a desire to receive more information.ConclusionsMany pediatricians are not confident in MSKe and are less confident compared to other bodily systems. There is need for greater training and awareness about the importance of MSKe at both undergraduate and postgraduate level. As a simple validated clinical skill, there is considerable potential to increase teaching of pGALS and thereby ultimately potentially improve MSKe performance in clinical practice.     

Obstructing giant post-inflammatory polyposis in ulcerative colitis: Case report and review of the literature

BackgroundPost-inflammatory polyps > 15 mm in diameter or length are termed “giant”. This benign and rare sequel of ulcerative colitis or colonic Crohn's disease can mimic colorectal carcinoma.ObjectiveTo illustrate this rare complication of inflammatory bowel disease and outline the characteristic radiological, endoscopic and histopathological features, by reviewing all previously published cases of giant post-inflammatory polyps in the English literature.ResultsReports of 81 giant post-inflammatory polyps in 78 patients were identified by systematic review of the literature. The incidence of giant post-inflammatory polyps is related to the extent of ulcerative colitis (incidence: 0%, 30%, and 70%, in proctitis, left-sided, and extensive disease, respectively). These lesions are typically located in the transverse or descending colon. Giant post-inflammatory polyps are as common in Crohn's disease (n = 36) as in ulcerative colitis (n = 42, 54%). Clinical presentations varies, including pain (n = 29), rectal bleeding (n = 20), diarrhoea (n = 19), luminal obstruction (n = 15), or a palpable mass (n = 11). Symptomatic presentation results in surgical resection. Clinical details and outcomes are comprehensively tabulated.ConclusionRecognition of this rare entity will prevent unnecessary radical surgical resection for presumed carcinoma. It highlights the need for clinical, radiological, endoscopic and histopathological correlation.