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.     

Apport et limites des « ECOS », « examen clinique au lit du malade » et « appréciation globale de stage » comme modalité d’évaluation de fin de stage. Expérience de deux services de médecine interne

IntroductionDuring placements, there is an opportunity to learn clinical skills and to assess their application. However, it represents two different goals. The validity of an end-of-placement assessment is questionable, as the medical competency is contextual. We decided to evaluate the contribution and limits of different assessment modalities as an end-of-placement assessment.Material and methodsInternal medicine clerks were assessed using the Mini-Cex grid by a structured objective clinical examination (OSCE), a long-case clinical examination (LCE) and a global end-of-placement marking (GEPM). Following these evaluations, students and teachers fulfilled an open questionnaire.ResultsIn 2021, 41 students and 16 teachers participated in the study. Physical examination was evaluated in 0%, 97% et 76% of cases during OSCE, LCE and GEPM, respectively; teaching skills were assessed for 100, 42 et 49% of students in OSCE, LCE and GEPM, respectively. As compared to OSCE, there was a perceived superiority of LCE regarding its formative value (P = 0.07 and P = 0.03) and its summative value (P = 0.0007 and P = 0.02), for students and teachers, respectively. Qualitative analysis highlights the breadth of clinical skills that could be assessed during OSCE stations. Integration into a team was an additional skill that could specifically be assessed during GEPM. GEPM could also take into account the progress made during placement.ConclusionDespite its subjectivity, LCE seemed to be the preferred modality for an end-of-rotation assessment.     

Diabetes care in Ireland: A survey of general practitioners

AimTo investigate the organisation of diabetes care in general practice in Ireland and identify areas for future development.MethodsSurvey of a representative sample of 600 general practitioners (GPs). The questionnaire contained closed and open-ended questions addressing 4 topics; characteristics of the practice, diabetes care delivery, use of services and opportunities for developing diabetes care.ResultsThe response rate was 44% (n = 262). There were an additional 86 responses to a follow-up shortened version of the survey resulting in a 58% response rate for 9 key questions. The majority of respondents were from an urban (43%, n = 112) or a mixed area (39%, n = 101) and 19% of practices were single-handed (n = 66). The reported prevalence in participating practices was 0.7% for Type 1 diabetes and 2.8% for Type 2 diabetes. Forty-five percent of GPs maintained a diabetes register (n = 157) while 53% reported using guidelines (n = 140). A formal call recall system was reported by 30% (n = 78) with a further 20% (n = 54) reporting a regular if informal approach to calling patients for review. With regard to the use of diabetes related services 63% reported direct access to a dietician (n = 165), 57% direct access to chiropody services (n = 149) and 89% had direct access to retinopathy screening (n = 234). There was a significant association between maintaining a diabetes register and other aspects of care delivery such as engaging in formal recall (p < 0.001), using guidelines (p < 0.001) and a declared special interest in diabetes (p = 0.001). Of a number of choices 75% of GPs thought that training was the principal opportunity for improving diabetes care. In response to the open-ended questions GPs cited lack of resources, time constraints and workload as barriers to effective care delivery.ConclusionsDelivery of diabetes care in Ireland remains largely unstructured. Key challenges to improving diabetes care appear to extend to the system and organisational level of care delivery.     

Significance of platelets to lymphocytes and platelets to haemoglobin ratios in patients with systemic sclerosis

BackgroundSystemic sclerosis (SSc) is a progressive autoimmune connective tissue disease. Platelets to lymphocytes (PLR) and platelets to haemoglobin ratios (PHR) are emerging biomarkers used in the assessment of activity and severity of various autoimmune diseases. This study was designed to clarify the association of PLR and PHR with SSc disease activity and its different manifestations.MethodA cross-sectional study involved sixty SSc patients. Demographic, clinical data and investigations were done.ResultsPLR and PHR were correlated positively with ESR (r = 0.351, p = 0.003*), (r = 0.620, p = 0.000**), CRP (r = 0.417, p = 0.001*), (r = 0.305, p = 0.018**) and SSc activity index (r = 0.292, p = 0.024*), (r = 0.359, p = 0.005*). PLR and PHR were highly significantly related to digital ulcerations, musckeloskeletal, and pulmonary manifestations. Also, they had a significant relation to ground glass abnormalities on HRCT, mild restriction in pulmonary function tests and anti-scleroderma-70 antibodies. The cutoff value for PLR was 107.8 with high sensitivity 97.9% and specifity 92.3%, area under the curve (AUC = 0.723, P 0.015) on receiver operating characteristic curve (ROC). PHR AUC (0.799, P .001), cut value was 23.5 at 95.7% sensitivity and 84.6% specifity.ConclusionPLR and PHR were significantly related to digital ulcerations, musculoskeletal, and pulmonary manifestations and can be considered as predictive biomarkers for the assessment of SSc disease activity and severity.     

E23K variant in KCNJ11 gene is associated with susceptibility to type 2 diabetes in the Mauritanian population

AimsMany genetic association studies reported the contribution of KCNJ11 gene to type 2 diabetes susceptibility in different populations. We aimed to evaluate the association between E23K variant of KCNJ11 and type 2 diabetes in the Mauritanian population.Materials and methodsWe performed a case-control association study including 135 type 2 diabetes Mauritanian patients and 135 controls. Genotyping for the E23K variant was performed using a TaqMan allelic discrimination assay.ResultsWe found significant association between KCNJ11 E23K variant and type 2 diabetes (Global model, OR = 2.08, 95% CI = 1.09–3.97, p = 0.026). In the Moor ethnic group, E23K was also associated with type 2 diabetes in the general model (OR = 2.08, 95% CI = 1.09–3.97, p = 0.026) and under the dominant model (OR = 2.49, 95% CI = 1.12–5.55, p = 0.026). In the Mauritanians of African descent, KK genotype was not found. Besides, E23K variant was not associated with type 2 diabetes (OR = 0.69, 95% CI = 0.04–11.32, p = 0.793).ConclusionsOur results revealed the risk of type 2 diabetes conferred by KCNJ11 E23K gene variant in the Mauritanian population.     

Evaluation of an Advanced Physical Diagnosis Course Using Consumer Preferences Methods: The Nominal Group Technique

BackgroundCurrent evaluation tools of medical school courses are limited by the scope of questions asked and may not fully engage the student to think on areas to improve. The authors sought to explore whether a technique to study consumer preferences would elicit specific and prioritized information for course evaluation from medical students.MethodsUsing the nominal group technique (4 sessions), 12 senior medical students prioritized and weighed expectations and topics learned in a 100-hour advanced physical diagnosis course (4-week course; February 2012). Students weighted their top 3 responses (top = 3, middle = 2 and bottom = 1).ResultsBefore the course, 12 students identified 23 topics they expected to learn; the top 3 were review sensitivity/specificity and high-yield techniques (percentage of total weight, 18.5%), improving diagnosis (13.8%) and reinforce usual and less well-known techniques (13.8%). After the course, students generated 22 topics learned; the top 3 were practice and reinforce advanced maneuvers (25.4%), gaining confidence (22.5%) and learn the evidence (16.9%). The authors observed no differences in the priority of responses before and after the course (P = 0.07).ConclusionsIn a physical diagnosis course, medical students elicited specific and prioritized information using the nominal group technique. The course met student expectations regarding education of the evidence-based physical examination, building skills and confidence on the proper techniques and maneuvers and experiential learning. The novel use for curriculum evaluation may be used to evaluate other courses—especially comprehensive and multicomponent courses.     

Association between fibromyalgia syndrome clinical severity and body composition. A principal component analysis

IntroductionThe type of body composition modulates the severity of some musculoskeletal conditions, in fibromyalgia syndrome (FMS), this type of association remains relatively unexplored.ObjectiveTo analyze the association between the type of body composition and FMS using Principal Component Analysis (PCA). The FMS clinical outcome measures were: Symptom Severity Scale (SSS), Widespread Pain Index (WPI; and Fibromyalgia Impact Questionnaire (FIQ).MethodsForty-three women with FMS (ACR 2010 criteria) were clinically and anthropometrically evaluated. The anthropometric data were integrated into two indicators using a PCA methodology (PCA-Fat and PCA-muscle). Additionally, the patients were classified into high and low categories for each clinical indicator, which were used as dependent variables in binomial logistic regression (BLR) models.ResultsWe found a positive correlation between PCA-Fat with WPI (r = 0.326, P = .043) and FIQ (r = 0.325, P = .044), and negative correlation (r = ?0.384, P = .013) between PCA-muscle and SSS. In the BLR analysis, PCA-Fat was a significant predictor for high WPI (OR = 2.477, P = .038); while for high SSS, PCA-muscle (OR = 0.303, P = .009) was an inversely significant predictor.ConclusionsThe results suggest that the volume of fat mass can negatively modulate the severity of FMS. We propose that the evaluation of body composition should be a basic element for the clinical approach of patients with FMS.     

Clinical characteristics and outcomes of community-onset acute pyelonephritis caused by Escherichia coli in elderly patients

PurposeTo evaluate clinical characteristics and outcomes of community-onset acute pyelonephritis (APN) caused by Escherichia coli in elderly patients.Patients/methodsCases of adult patients with community-onset APN caused by E. coli were collected from 10 referral centres in Korea from November 2006 to August 2007. Demographic, clinical and microbiological data were analysed.ResultsDiabetes mellitus (38% vs 23%, P = 0.036), chills (83% vs 66%, P = 0.015), gastrointestinal symptoms (55% vs 34%, P = 0.008), altered mental status on admission (21% vs 9%, P = 0.032), acute renal failure (17% vs 3%, P = 0.004) and concomitant bacteraemia (34% vs 17%, P = 0.015) were more frequently observed in patients aged ≥ 65 years compared with those aged < 65 years. The overall intergroup mortality rates did not differ. However, diabetes mellitus (OR = 3.54, 95% CI = 1.40–9.00, P = 0.008) and age of ≥ 65 years (OR = 2.34, 95% CI = 1.05–5.19, P = 0.037) were significantly related to a longer duration of hospital stay (≥ 5 days).ConclusionElderly patients with APN have a higher frequency of atypical manifestations, such as gastrointestinal symptoms, altered mental status and longer durations of hospital stays. Age was independently associated with longer duration of hospital stays among patients with APN. Careful diagnosis and appropriate treatment are crucial in the management of elderly patients with APN.     

Prise en charge du rétrécissement mitral durant la grossesse au centre hospitalo-universitaire d’Oran : à propos de 83 cas

IntroductionThe management of pregnancy in patients with mitral valve stenosis disease continues to pose a challenge to the clinician.ObjectiveThe aim of study was to evaluate the association between mitral valve stenosis and maternal and fetal out come.Materiel and methodEighty-three pregnant women with mitral valve disease, followed-up from 2009 to 2012, were prospectively evaluated medical history, NYHA class assessment, ECG and echocardiography were performed during pregnancy and after delivery.ResultsWomen with mitral stenosis had significantly clinical higher incidence of complications deterioration of clinical status was observed (44.57%, P = 0.0001) congestive heart failure had observed (27.71%, P = 0.0001), hospitalization (33.73%, P = 0.0001), need of cardiac medications (53.75%, P = 0.009), arrhythmias (16%, P < 0.05), New born outcome, mitral stenosis had an effect on fetal outcome. We had increasing preterm, delivery (17.50%, P = 0.018), hypotrophy (20.48%, P = 0.001), intra-uterine growth retardation (12.04%, P = 0.011) new born hospitalizations (13.25%, P = 0.03) Increased maternal morbidity and unfavorable fetal outcome was seen mostly in patients with moderate and severe mitral stenosis.ConclusionPregnant with critical mitral stenosis form a high-risk groups of life-threatening complications. There is need for close maternal follow-up and fetal surveillance and repair of mitral stenosis should be performed before pregnancy.     

Identification des facteurs associés à la réussite aux examens cliniques objectifs et structurés dans la faculté de médecine de Rouen

ContextObjective structured clinical examination (OSCE) became a national exam at the end of medical studies in France. The aim of this study was to identify the predictive factors for success at OSCEs.MethodsAurvey query after the OSCEs was completed by fifth-year medicine students at Rouen Uuniversity.. Data on continuous variables were compared using the Mann-Whitney test. Data on quantitative variables were compared using the Spearman's correlation.ResultsTwo hundred and thirty-nine students, i.e., 98.7 % of the students, responded to the query. The median (IQR 25–75) OSCE score was 13.6/20 (12.5–14.2). Students’ personal factors significantly associated with a higher OSCE performance were female sex (median score of 13.7 versus 13.4; P = 0.03) and good health during the clerkship (median score of 13.6 versus 12.6; P = 0.02). A higher OSCE performance was associated with an increased number (≥6)  of medicine clerkships  (median score of 13.8 versus 13.3; P = 0.02) and a decreased number (<3) of surgery clerkships (median score of 13.7 versus 12.9; P = 0.009). There was no correlation between the OSCE score and medical school performance (Spearman's correlation, r = 0.24).ConclusionHomogenization of student's clerkships, assistance to students with health problems seem to be teaching approaches to promote success at OSCEs.     

Does uric acid-lowering treatment slow the progression of chronic kidney disease? A meta-analysis of randomized controlled trials

IntroductionHyperuricemia has been proposed as an independent factor in the development and progression of chronic kidney disease (CKD). However, the effect of uric acid-lowering therapies on delaying CKD progression is still uncertain. Therefore, this systemic review aims to assess the effect of uric acid-lowering therapies on renal outcomes in pre-dialysis CKD patients.MethodsPubMed, Cochrane Library, and Lilacs databases were searched until April 24, 2021, for randomized clinical trials of CKD patients on uric acid-lowering treatment with xanthine-oxidase (XO) inhibitors. The weighted mean difference (WMD) or standard mean difference (SMD) with confidence interval (CI) were pooled using a random-effects model.ResultsAmong 567 studies found, eighteen met the inclusion criteria (n = 2463 participants). Compared to the patient's control group, the WMD for the glomerular filtration ratio (GFR) and serum creatinine changes of the treated group was 2.02 ml/min/1.73 m² (95%CI 0.41 to 3.63, P = 0.014) and −0.19 mg/dl (95%CI −0.34 to −0.04, I² = 86.2%, P = 0.011), respectively. Subgroup analyses showed that the difference in follow-up time and CKD population type in the studies may explain the controversy about the role of uric acid-lowering therapies in CKD progression. The GFR and creatinine outcomes analysis by types of XO inhibitors showed no difference between the control and treated groups. Uric acid-lowering therapies were strongly associated with decreased serum uric acid and urinary protein–creatinine ratio and urinary albumin–creatinine ratio.ConclusionsThese findings suggest that uric acid-lowering treatment may slow CKD progress and reduce protein and albumin excretion. However, larger and properly powered randomized clinical trials with specific CKD populations are needed to confirm these findings.     

The impact of angiotensin converting enzyme insertion/deletion gene polymorphism on diabetic kidney disease: A debatable issue

ObjectiveThe objective of this study was to evaluate the influence of ACE I/D gene polymorphisms on diabetic kidney disease (DKD) risk.MethodsAll eligible investigations were identified, the number of various genotype in the case and control group were reviewed. The pooled analysis was performed using Stata software.ResultsIn overall subjects, 24,321 participants with 12,961 cases and 11,360 controls were included. the pooled analysis showed a significant link between D allele, DD or II genotype and DKD risk (D versus I: OR = 1.316, 95% CI: 1.213–1.427, P = 0.000; DD versus ID + II: OR = 1.414, 95% CI: 1.253–1.595, P = 0.000; II versus DD + ID: OR = 0.750, 95% CI: 0.647–0.869, P = 0.000). The subgroup pooled analysis showed that ACE I/D gene polymorphism was correlated with DKD both in Asian and in Chinese population. In addition, ACE I/D gene polymorphism was correlated with type 2 DKD (D versus I: OR = 1.361, 95% CI: 1.243–1.490, P = 0.000; DD versus ID + II: OR = 1.503, 95% CI: 1.310–1.726, P = 0.000; II versus DD + ID: OR = 0.738, 95% CI: 0.626 –0.870, P = 0.000). However, there was no obvious correlation in Caucasian subjects and type 1 diabetic patients.ConclusionACE I/D polymorphisms were correlated with DKD in Asian and type 2 diabetic populations. ACE D allele/DD genotype might be a risk factor, while ACE II genotype might be a protective factor for DKD.     

Incidence and risk factors of peripheral venous catheter-related adverse events in cardiology department of a Tunisian university hospital: A prospective observational study

AimThe purpose of our study was to determine the incidence and risk factors of Peripheral Venous Catheter-Related Adverse Events (PVCAEs) in a cardiology department of a university hospital.Patients and methodsWe carried out a prospective observational study from Mars 2017 to May 2017 in the cardiology department of the University Hospital of Farhat Hached in Sousse, Tunisia. During this period, we actively followed-up all inserted PVCs (every 12 hours) from insertion up to 48 hours after removal. Regression analyses were applied and significance limits were set at P < 0.05.ResultsData were analysed for 210 PVCs (794 PVC-days) in 148 patients. The incidence of PVCAEs was 33.33% with density of incidence of 8.81/1000 PVC-days. PVCAEs were mainly pain (50%) and mechanical events (31.42%). Infections accounted for 11.42%. The most frequent mechanical PVCAEs, was haematoma (15.71%). Multivariate analysis revealed as independent factors for the occurrence of PVCAEs: the hydro electrolytic nature of the injected product (OR = 13.42, P < 10−3), the medicinal nature of the injected product (OR = 5.08, P = 0.003), bad cutaneous state (OR = 8.08, P = 0.003), admission during nightshift (OR = 3.76; P = 0.014) and advanced age (OR = 1.04, P = 0.042).ConclusionMulticenter studies would be very useful to better analyze risk factors associated with PVCAEs.     

Relationship between blood pressure,cognitive function and education level in elderly patients with diabetes: A preliminary study

AimsThis study aimed to assess the relationship between blood pressure and cognitive function in elderly patients with diabetes mellitus (DM).MethodsA total of 32 patients with DM aged ≥ 65 years (seven women and 25 men; mean ± SD age: 74.3 ± 6.4 years) were included in this cross-sectional study. Relationships between blood pressure and neuropsychological tests were determined using Spearman's rank correlations (ρ) and multivariable linear regression models.ResultsLower diastolic blood pressure was associated with lower scores on the Frontal Assessment Battery (ρ = 0.32, P = 0.02), longer times to complete the Trail Making Test Part B (ρ = 0.51, P = 0.003), lower scores for the Finger Tapping Test (ρ = 0.36, P = 0.046) and less verbal fluency (ρ = 0.36, P = 0.047). In multivariable models, these relationships were attenuated after adjusting for levels of education.ConclusionThere was an association between lower diastolic blood pressure and poorer executive function in this cohort of elderly DM patients. These results underline the importance of systematic cognitive evaluation in elderly patients with DM, and suggest that a too-low diastolic blood pressure may have deleterious effects on mental function. Larger studies in the future are required to confirm these preliminary results.     

Predictive Factors of Severe Behçet's disease: A Longitudinal,Prospective Cohort Followed Between 1981–2020

IntroductionBehçet's disease (BD) is a systemic vasculitis of unknown cause. The spectrum of the disease ranges from mucocutaneous manifestations to other organ diseases with relevant morbidity. Associations between disease severity and male sex, earlier age at onset, and the presence of erythema nodosum have been described.ObjectivesTo evaluate clinical factors associated with manifestations of severe disease in a single-center cohort.MethodsA longitudinal, prospective, unicentric cohort study with patients followed in a specialized outpatient clinic between 1981 and 2020. Severe BD was defined as a Krause total clinical severity score >4 points.ResultsWe included 243 patients, of whom 31% were male, with an average follow-up time of 14.6 years. Regarding organ manifestations, all patients had mucous manifestations (N = 243, 100%), 133 (55%) skin, 104 (43%) joint, 71 (29%) ocular, 48 (20%) vascular, 47 (19%) neurological, 22 (9%) gastrointestinal and 1 (0.4%) cardiac involvement by BD. One hundred fifty-six (64%) patients were classified as having severe BD. Severe BD was more frequent in men (OR = 2.004, p = 0.024), increasing with age (OR = 1.021 per year, p = 0.037), in the presence of skin manifestations (OR = 4.711, p < 0.001), specifically erythema nodosum (OR = 8.381, p < 0.001), and pseudofolliculitis (OR = 2.910, p < 0.001).In the multivariate model, variables independently associated with severe BD were male gender (Adjusted OR = 1.961, p = 0.047), erythema nodosum (Adjusted OR = 8.561, p < 0.001) and pseudofolliculitis (Adjusted OR = 2.372, p = 0.007).DiscussionMale gender, erythema nodosum, and pseudofolliculitis were independently associated with severe BD forms and therefore should serve as warning signs to the clinician.     

Efficacy and safety of combined pegylated interferon/ribavirin therapy in the management of rheumatological manifestations of chronic HCV patients

BackgroundThe hepatitis C virus (HCV) epidemic is particularly devastating in Egypt where its prevalence is about 12%. Chronic HCV infection can result in the accumulation of immune complexes and stimulate antibodies, which can result in extrahepatic manifestations (EHM).Aim of the workTo assess the efficacy and safety of combined pegylated interferon and ribavirin therapy in the management of rheumatological EHM in HCV patients.Patients and methodsTwenty-seven out of 50 consecutive HCV patients with rheumatologic EHM were eligible and included in this study. All patients included in this study were subjected to full history taking, clinical examination and laboratory investigations.ResultsThe mean age of the patients was 43.8 ± 7.6 years. The clinical response of the patients was: 2 patients (7.4%) were complete clinical responders, 5 (18.5%) were partial responders, 3 (11.1%) showed relapse and 17 (63%) were non-responders. There was a significant improvement in the number of patients with fatigue, polymerase chain reaction positivity and elevated liver enzymes (p < 0.0001, p < 0.0001, p = 0.03, p = 0.01 respectively). There was no significant correlation between virological and clinical responses. There was a significant correlation between virological and biochemical responses (p = 0.02). Minor side effects of the AVT developed in 13 (48.1%) patients: anemia (n = 5), mild thrombocytopenia (n = 8), flu-like symptoms (n = 7) and mild depression (n = 1).ConclusionPeg IFN and ribavirin did not improve HCV rheumatological extrahepatic manifestations. Antiviral treatment may also induce or worsen autoimmune disorders and is sometimes associated with major immune-mediated adverse events.     

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).     

A meta-analysis of efficacy of topical steroids in eosinophilic esophagitis: From the perspective of histologic,clinical, and endoscopic outcome

BackgroundSwallowed topical steroids are a mainstay drug therapy for eosinophilic esophagitis (EoE), studies have demonstrated good histologic response, but with enormous discrepancy in clinical and endoscopic improvement. We conducted this meta-analysis to investigate the efficacy of topical steroids in EoE in histological, clinical and endoscopic improvement.MethodsSeveral databases were searched from inception to August 1, 2019 for randomized controlled trials (RCTs) comparing topical steroids with placebo for EoE in the short-term. The outcomes of interest mainly included basic characteristics of the studies, histologic, clinical, endoscopic response rate and adverse events. The results were pooled together using Reviewer Manager 5.3.5 software, and inconsistency was quantified using I² statistics.ResultsNine studies were eventually selected. The results showed that topical steroids were effective in inducing histologic response compared with placebo for both complete (OR 35.82, 95% CI 14.98–85.64, P < 0.0001; I² = 0, P = 0.72) and partial response (OR 28.44, 95% CI 8.56–94.47, P < 0.0001; I² = 70%, P = 0.0009). Moreover, topical steroids were useful in gaining clinical response (OR 2.53, 95% CI 1.14–5.60, P = 0.02; I² = 60%, P = 0.02) and endoscopic response (OR 3.51, 95% CI 1.47–8.36, P = 0.005; I² = 0, P = 0.57). Generally, topical steroids are well tolerated. The most common adverse events are infections and infestations (59 cases).ConclusionTopical steroids were effective in inducing histological, clinical and endoscopic response in the short-term, and the adverse events were almost tolerable; however, we should interpret the result of clinical and endoscopic response with caution.     

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.     

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.