Endocarditis: epidemiology, diagnosis and treatment

The current incidence of infective endocarditis (IE) is estimated as seven cases per 100,000 population per year and continues to increase. The prognosis is significantly influenced by proper diagnosis and adequate therapy. In cases with unconfirmed IE, besides careful clinical examination, transesophageal echocardiography is the imaging technique of choice. Culture-negative endocarditis requires either termination of antimicrobial treatment initiated without microbiological test results and reevaluation of blood samples or serological/molecular biological techniques to identify the causative organism. Antimicrobial therapy should established only after quantitative sensitivity tests of antibiotics, including evaluation of the minimal bactericidal concentrations (MBC) of established combinations of antibiotics. Concomitant kidney involvement, a significant impairment of the hepatic function or the combination therapy with oto- and/or nephrotoxic antibiotics, requires drug monitoring. Large (> 10 mm) vegetations attached to the mitral valve are linked with a high incidence of thromboembolic complications. In most of these cases, the indication for surgical intervention is given, especially if the MBC of the optimal combination of antibiotics is high (> 2 micrograms/ml). In the first three weeks after primary manifestation of signs and symptoms of IE, an index embolism is frequently followed by recurrences. If vegetations can still be demonstrated by echocardiography after an embolic event, surgical intervention should seriously be considered. Cerebral embolic events are no contraindication for surgery with use of the heart-lung machine, as long as cerebral bleeding has been excluded by cranial computed tomography immediately preoperatively and the operation is performed before a significant disturbance of the blood-brain barrier (< 72 hours) has manifested. A significant prognostic improvement has also been demonstrated for patients with early surgical intervention, after their clinical course was complicated by myocardial failure due to acute valve incompetence, acute renal failure, mitral kissing vegetations in primary aortic valve IE, and in patients with sepsis persisting for more than 48 hours despite adequate antimicrobial therapy.     

Mixed dementia: epidemiology,diagnosis, and treatment

Alzheimer's disease (AD) and vascular dementia (VaD) are the most frequent causes of dementia in older people. Although AD can be diagnosed with a considerable degree of accuracy, the distinction between isolated AD, VaD, and mixed dementia (MD), where both pathologies coexist in the same patient, remains a controversial issue and one of the most difficult diagnostic challenges. Although MD represents a very frequent pathology, especially in older people, as reported in neuropathological studies, the respective importance of degenerative and vascular lesions, their interaction in the genesis of dementia, and the mere existence of MD are still debated. Accurate diagnosis of MD is of crucial significance for epidemiological purposes and for preventive and therapeutic strategies. Until recently, pharmacological studies have generally focused on pure disease, AD or VaD, and have provided little information on the best therapeutic approach to MD. This article provides an overview of MD in older people. A retrospective review of the recent literature on prevalence, incidence, course, risk factors, diagnosis, and treatment of MD was performed. The article also emphasizes the need for further studies, including neuropsychological and functional evaluations, and neuroimaging and clinicopathological correlations to develop a better understanding of MD, which appears to be one of the most common forms of dementia.     

Mycobacterial disease: epidemiology, diagnosis, treatment, and prevention

TB is common in the setting of HIV-induced immunosuppression, especially among demographic groups with a high background prevalence of tuberculous infection. It is often the first (sentinel) infectious disease to appear, extrapulmonary and disseminated disease is common, the chest x-ray picture is frequently atypical, and the tuberculin skin test is often falsely negative. It therefore requires a high index of suspicion and an aggressive diagnostic approach to avoid missing HIV-related tuberculous disease, which is communicable from man to man by the aerosol route and which appears to be highly treatable with conventional anti-TB drugs. Identification and INH prophylaxis of tuberculous-infected, HIV-seropositive persons is likely to be very important in the prevention of tuberculous disease. MAI is also a very common pathogen that frequently produces extrapulmonary and disseminated disease among patients with AIDS. In contrast to TB, AIDS-related MAI disease occurs more uniformly among the AIDS risk groups, occurs late among the HIV-related infections, and is not effectively treated with current drug regimens.     

Nosocomial pneumonia: epidemiology, pathogenesis, diagnosis, treatment and prevention

Nosocomial pneumonia is the second most common nosocomial infection and the leading cause of death from hospital-acquired infection. Supine body position in mechanically ventilated patients, and cardiopulmonary resuscitation and continuous sedation are significant risk factors for developing nosocomial pneumonia. During the past 2 years some new therapeutic approaches for nosocomial pneumonia and modifications to established therapies have been described, such as optimal pharmacodynamic evaluations, monotherapy versus combination therapy, computer-assisted management programmes and antibiotic rotations.     

Peripheral tuberculous lymphadenitis: epidemiology, diagnosis, treatment, and outcome

We reviewed 106 patients referred to our institution for treatment of peripheral tuberculous adenitis to establish the epidemiologic, clinical, and pathologic manifestations of this disease. Tuberculous lymphadenitis occurred predominantly in young, foreign-born women a mean of 5 years after arrival in the United States. Tuberculin skin tests were positive in 94% of cases. Lymphadenopathy occurred most frequently in the neck (57%) or supraclavicular area (26%) and involved 1-3 nodes. Forty (38%) patients had an abnormal chest radiograph consistent with granulomatous infection. Culture-positive pulmonary tuberculosis was diagnosed in 41% of those patients with abnormal chest radiographs.Fine needle aspiration was an essential step in the evaluation and diagnosis of tuberculous lymphadenitis. Granulomas were seen in 61% of fine needle aspirates and 88% of surgical biopsies. Positive cultures for Mycobacterium tuberculosis were obtained from 62% of fine needle aspirate samples and 71% of excisional biopsies. The presence of necrosis and/or neutrophilic inflammation in tissue samples correlated with culture positivity. Given the high yield of positive cultures from fine needle aspirates, surgery was rarely indicated as an initial step in immunocompetent adults.In this cohort, 101 patients received a final diagnosis of peripheral tuberculous lymphadenitis. Eighty-two percent received their entire therapy under direct observation, and response to antituberculous therapy was uniformly successful. Paradoxical expansion of adenopathy was seen in 20% of all patients and was more commonly noted in human immunodeficiency virus-seropositive patients.We present a diagnostic algorithm based on our experience.     

Thromboembolic complications of cancer: epidemiology,pathogenesis, diagnosis,and treatment

The association between malignancy and clinical thrombosis has been recognized for nearly 140 years. The purpose of this review is to examine our current understanding of thrombosis as a complication of cancer and cancer therapy. The review includes a discussion of the epidemiology, pathophysiology, diagnosis and treatment.     

Achalasia: A review of clinical diagnosis,epidemiology, treatment and outcomes

Achalasia is a neurodegenerative motility disorder of the oesophagus resulting in deranged oesophageal peristalsis and loss of lower oesophageal sphincter function.Historically,annual achalasia incidence rates were believed to be low,approximately 0.5-1.2 per 100000.More recent reports suggest that annual incidence rates have risen to 1.6 per 100000 in some populations.The aetiology of achalasia is still unclear but is likely to be multi-factorial.Suggested causes include environmental or viral exposures resulting in inflammation of the oesophageal myenteric plexus,which elicits an autoimmune response.Risk of achalasia may be elevated in a sub-group of genetically susceptible people.Improvement in the diagnosis of achalasia,through the introduction of high resolution manometry with pressure topography plotting,has resulted in the development of a novel classification system for achalasia.This classification system can evaluate patient prognosis and predict responsiveness to treatment.There is currently much debate over whether pneumatic dilatation is a superior method compared to the Heller’s myotomy procedure in the treatment of achalasia.A recent com-parative study found equal efficacy,suggesting that patient preference and local expertise should guide the choice.Although achalasia is a relatively rare condition,it carries a risk of complications,including aspiration pneumonia and oesophageal cancer.The risk of both squamous cell carcinoma and adenocarcinoma of the oesophagus is believed to be significantly increased in patients with achalasia,however the absolute excess risk is small.Therefore,it is currently unknown whether a surveillance programme in achalasia patients would be effective or cost-effective.     

Infection with human papillomavirus: Update on epidemiology, diagnosis, and treatment

Human papillomavirus (HPV) infection is the most common sexually transmitted viral disease worldwide. Low-risk types of HPV (eg, HPV-6 and HPV-11) are the causative agents of genital warts, whereas high-risk types (eg, HPV-16 and HPV-18) have been associated with anogenital cancer, particularly cervical cancer. Cervical cancer remains the second most common cancer in women worldwide. Recent advances have led to a better understanding of how HPV causes cancer on a molecular level and of the immunologic response to HPV. Methods to detect HPV infection have been improved, and a new treatment method for genital warts has been developed. The production of empty capsids of HPV done using recombinant technology has led to the development of serologic assays for HPV. The empty capsids are now the basis of clinical trials of vaccines to prevent HPV infection and disease.     

Gastrointestinal stromal tumors: epidemiology, clinical picture, diagnosis, prognosis and treatment

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. They originate from the myenteric ganglion cells, termed the interstitial Cajal cells. The majority, i.e. 95% of GIST, show expression of the membrane receptor protein CD117 with a tyrosine kinase activity c-kit. Gastrointestinal stromal tumors constitute less than 1% of all digestive tract tumors. They may be benign or malignant (30%), and occur in every part of the gastrointestinal tract, however the stomach is the most common localization. They develop with the same prevalence in men and in women, usually above the age of 50 years. The peak incidence is observed between the fifth and the sixth decade of life. Symptoms are not typical and depend on the localization and the tumor size. About 10-30% of GIST are completely asymptomatic, and are discovered accidentally during the endoscopy or X-rays evaluation as well as during surgical interventions performed for various reasons. The malignant tumors metastasize most commonly to the liver and peritoneum. The metastases are rarely found in the lungs, pleura and bones. The detection of GIST is based on imaging, endoscopy, histological and immunohistochemical examinations. A useful and promising diagnostic procedure is positron emission tomography. The final diagnosis is mostly based on the pathologic findings of the removed tumor. The prognosis of GIST depends on its size, mitotic activity in 50 high power fields and mucosal infiltration. Radical surgery is the best treatment of GIST.     

Recent developments in epidemiology, treatment, and diagnosis of tuberculosis

The resurgence in cases of active tuberculosis in North America in the past decade has prompted increases in funding for tuberculosis treatment, research, and education. As a result, the number of new cases of tuberculosis has declined and cases occur in smaller pockets of well-characterized populations, such as communities of foreign-born persons and socioeconomically disadvantaged groups. New strategies for the treatment of both active and latent tuberculosis may soon include the newly licensed, long-acting rifamycin, rifapentine, but further studies are needed to determine optimal dosing regimens for this agent. Experts in tuberculosis and HIV infection have made headway in defining the optimal therapy for each current therapeutic option, and recently published guidelines are a useful document for clinicians. Rifabutin-based regimens are one approach toward achieving the optimal treatment of both diseases simultaneously. Finally, newly licensed molecular diagnostic tests for direct use on clinical specimens are intriguing, but their clinical utility remains to be defined.     

Pneumonia due to Chlamydia pneumoniae in children: epidemiology, diagnosis, and treatment

The term "atypical" pneumonia has been used to differentiate infections caused by Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella, and other related organisms from pneumonia caused by classic bacteria, the prototype being Streptococcus pneumoniae. However, recent studies demonstrated that the clinical presentation of pneumonia due to atypical pathogens cannot readily be differentiated from those caused by "typical" bacteria. This is further complicated by the observation that coinfections with atypical pathogens and other bacteria are frequent. Nonetheless, the term "atypical" can be useful, as these organisms share a number of characteristics that separate them from "typical" bacteria. They are either obligate or facultative intracellular parasites that cannot be isolated using routine microbiologic methods. The most commonly used method of diagnosis of these infections is serology, which has significant limitations. Although C. pneumoniae is now recognized worldwide as a common cause of respiratory infections in adults and children, major gaps remain in our knowledge of the biology of this organism and how it causes disease, in major part due to the lack of readily available, standardized diagnostic methods.     

Pancreatic cancer: A review of clinical diagnosis,epidemiology, treatment and outcomes

This review aims to outline the most up-to-date knowledge of pancreatic adenocarcinoma risk, diagnostics, treatment and outcomes, while identifying gaps that aim to stimulate further research in this understudied malignancy. Pancreatic adenocarcinoma is a lethal condition with a rising incidence, predicted to become the second leading cause of cancer death in some regions. It often presents at an advanced stage, which contributes to poor five-year survival rates of 2%-9%, ranking firmly last amongst all cancer sites in terms of prognostic outcomes for patients. Better understanding of the risk factors and symptoms associated with this disease is essential to inform both health professionals and the general population of potential preventive and/or early detection measures. The identification of high-risk patients who could benefit from screening to detect pre-malignant conditions such as pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasms and mucinous cystic neoplasms is urgently required, however an acceptable screening test has yet to be identified. The management of pancreatic adenocarcinoma is evolving, with the introduction of new surgical techniques and medical therapies such as laparoscopic techniques and neo-adjuvant chemoradiotherapy, however this has only led to modest improvements in outcomes. The identification of novel biomarkers is desirable to move towards a precision medicine era, where pancreatic cancer therapy can be tailored to the individual patient, while unnecessary treatments that have negative consequences on quality of life could be prevented for others. Research efforts must also focus on the development of new agents and delivery systems. Overall, considerable progress is required to reduce the burden associated with pancreatic cancer. Recent, renewed efforts to fund large consortia and research into pancreatic adenocarcinoma are welcomed, but further streams will be necessary to facilitate the momentum needed to bring breakthroughs seen for other cancer sites.     

Problems of epidemiology,diagnosis and treatment of caseous pneumonia

In 1992-2001, the growth rates of new cases of caseous pneumonia were 50% greater than those of the total new cases of respiratory tuberculosis. Examining the specific features of the diagnosis and treatment of 128 new cases of caseous pneumonia has identified diagnostic criteria for this form of tuberculosis. The leading criteria are X-ray signs of caseous and necrotic lung tissue lesion; clinical and laboratory signs of significant endotoxicosis and immunodeficiency. The use of extracorporeal immunopharmacotherapy with diucifon in 53 patients and the retrosternal injection of isoniazid in combination with hydrocortisone in 43 patients have shown their efficiencies in the treatment of patients with caseous pneumonia.     

梅毒流行病学和诊疗现状分析

梅毒是由梅毒螺旋体感染引起的一种慢性传染病,主要传播方式为性接触、血液传播和垂直传播,危害性极大。近年来,梅毒疫情呈上升趋势,已成为我国发病率最高的性传播疾病。梅毒的发病率存在地区差异性,发病人群有从高危人群向普通人群扩大的趋势,尤其是农民工、老年患者发病率较高。目前,梅毒的实验室诊断主要有病原学诊断、血清学诊断、组织病理诊断、基因诊断和脑脊液检查。血清学检查因其简便、可靠,目前临床上应用最为广泛。梅毒的治疗应遵循早期、规范、足量的原则。青霉素是治疗梅毒的首选药。     

Inhalational anthrax: epidemiology, diagnosis, and management

Anthrax, a disease of great historical interest, is once again making headlines as an agent of biological warfare. Bacillus anthracis, a rod-shaped, spore-forming bacterium, primarily infects herbivores. Humans can acquire anthrax by agricultural or industrial exposure to infected animals or animal products. More recently, the potential for intentional release of anthrax spores in the environment has caused much concern. The common clinical manifestations of anthrax are cutaneous disease, pulmonary disease from inhalation of anthrax spores, and GI disease. The course of inhalational anthrax is dramatic, from the insidious onset of nonspecific influenza-like symptoms to severe dyspnea, hypotension, and hemorrhage within days of exposure. A rapid decline, culminating in septic shock, respiratory distress, and death within 24 h is not uncommon. The high mortality seen in inhalational anthrax is in part due to delays in diagnosis. Classic findings on the chest radiograph include widening of the mediastinum as well as pleural effusions. Pneumonia is less common; key pathologic manifestations include severe hemorrhagic mediastinitis, diffuse hemorrhagic lymphadenitis, and edema. Diagnosis requires a high index of suspicion. Treatment involves supportive care in an intensive care facility and high doses of penicillin. Resistance to third-generation cephalosporins has been noted. Vaccines are currently available and have been shown to be effective against aerosolized exposure in animal studies.