Serial kinetics of the antibody response against the complete Brucella melitensis ORFeome in focal vertebral brucellosis

Human brucellosis is a common zoonosis worldwide. Here we present a case of focal vertebral brucellosis in a 71-year-old Mexican-American woman who contracted infection from unpasteurized goat milk. Standard agglutination serology was negative; the diagnosis was established by the isolation of Brucella melitensis from abscess fluid. A B. melitensis protein microarray comprised of nearly all proteins encoded by the bacterial genome was used to determine the kinetics of this patient's antibody responses to the complete collection of open reading frames existing in the genome (ORFeome). Three patterns of antibody responses against B. melitensis antigens were seen for serum samples obtained on days 0 (pretreatment), 14, 49, 100, and 180: (i) stable titers over time, (ii) a steady fall in titers, and (iii) an initial rise in titers followed by declining titers. Sera from this patient with chronic brucellosis recognized some of the same B. melitensis proteins as those recognized by sera from acute/subacute, blood culture-positive brucellosis patients but also recognized a distinct set of proteins. This study is the first to determine the kinetics of the human antibody responses to the complete repertoire of proteins encoded by a bacterial genome and demonstrates fundamentally different immunopathogenetic mechanisms between acute human brucellosis and chronic human brucellosis. While an extension of these findings to a larger patient population is necessary, these findings have important clinical and diagnostic implications and lead toward new insights into the fundamental immunopathogenesis of brucellosis.     

Pulsatile Left Ventricular Assist Devices: What Is the Role in the Modern Era?

With the widespread use of continuous-flow ventricular assist devices (VADs), the role of pulsatile VADs remain in question. In acute cardiogenic shock, pulsatile VADs maximize perfusion pressure, restore end organ perfusion, and maximally unload the pulmonary circulation and right heart. In addition, pulsatile left VADs allow for easy conversion to biventricular support using one platform, in the case of acute right ventricular failure. Pulsatile VADs still have a major role in the treatment of acute cardiogenic shock.     

Optimizing multidetector CT for visualization of splenic vascular injury. Validation by splenic arteriography in blunt abdominal trauma patients

Nonoperative management of blunt splenic injury is the treatment of choice in hemodynamically stable patients. Detection of vascular injury by multidetector CT (MDCT) is the most significant factor predicting the need for endovascular treatment. This study evaluated the timing of the appearance of vascular lesions during angiography. Images from 20 patients embolized for pseudoaneurysms (PSA) were evaluated. Angiograms were reviewed for phase and timing of PSA. Admission MDCT was reviewed for injury grade and PSA. Initial MDCT evaluation indicated grade III and IV splenic injuries in 9 and 11 patients, respectively. PSA was seen on MDCT in 14/20 (70%) patients. Time from opacification of the aorta to vascular injury was 1.32 s for arterial phase injuries compared with 2.05 s for postcapillary injuries (P = 0.097). Angiography demonstrated 15 vascular injuries during the arterial and 5 in the venous phase. Of injuries seen during arterial phase angiography, 10/15 (66%) were identified on MDCT. Of the five injuries that exhibited postcapillary-phase findings, 4/5 (80%) demonstrated PSA (P = 0.5). Vascular lesions are a better indicator of subsequent clinical deterioration than splenic injury grade. PSAs are more frequently seen in postcapillary vascular injuries than arterial phase lesions with the current timing of MDCT. In a subset of patients in whom splenic injury grades III and IV warrant angiography, PSAs are not initially demonstrated on MDCT. Therefore, alteration of MDCT timing parameters to better correlate with arterial phase angiography may improve initial diagnosis of vascular injury.     

Clinical implications of anatomical wear characteristics in slipped capital femoral epiphysis and primary osteoarthritis

BACKGROUND: This study compares the wear characteristics in slipped capital femoral epiphysis (SCFE) with those of primary osteoarthritis (OA) in adult patients with advanced arthritis. METHODS: One hundred femoral heads and proximal neck specimens were studied from SCFE patients (16 hips) and from primary OA (84 hips) patients undergoing total hip arthroplasties (THA). Grade 4 chondromalacia was plotted on a 2-dimensional (2-D) paper grid. Computer tomographic scans were used to create 3-D models of the femoral head and neck to trace the wear patterns. RESULTS: The SCFE group was characterized by (1) loss of neck-head offset, (2) acetabular neck impingement, and (3) loss of superior peripheral articular cartilage adjacent to superior neck. Whereas the primary OA group showed (1) preservation of head-neck offset, (2) absence of acetabular neck impingement, and (3) preservation of superior peripheral articular cartilage. The 3-D modeling in SCFE specimens demonstrated acetabular impingement on the superior lateral femoral neck causing the femur to externally rotate with flexion. The SCFE patients undergoing THA on average were 11 years younger than those with primary OA. The study strongly suggests that the abnormal rotation of the femoral head in SCFE patients causes thinner superior lateral articular cartilage on the femoral head to articulate with the acetabulum. The pistol-grip deformity of the proximal femur in the SCFE group results in hip impingement, which explains why hip flexion and internal rotation can be restricted. CONCLUSIONS: There was a premature development of advanced OA of the adult hip joint in SCFE patients. This was associated with hip impingement caused by loss of the head-neck offset and reorientation of the articular cartilage of the femoral head. Unless the femoral head is redirected in patients with SCFE, the benefits of limited hip preservation debridement procedures are not expected to delay the onset and progression of arthritis. LEVEL OF EVIDENCE: Prognostic study.     

Efficacy of procedural treatments for pediatric hidradenitis suppurativa: A systematic review

Hidradenitis suppurativa (HS) is a painful, inflammatory skin disease that has historically been understudied in the pediatric population. Procedural interventions, such as surgical excisions, skin grafts, and lasers, are important for comprehensive HS disease management. However, there is a lack of data on procedural treatments for HS in pediatric patients. The purpose of this study was to conduct a systematic review of the literature on the efficacy and safety of procedural treatments for HS in pediatric patients. In April 2022, MEDLINE and EMBASE databases were searched for articles on the efficacy of procedural treatments for HS in patients <18 years of age. Two independent reviewers extracted data from relevant studies. From 1974 to 2021, 23 articles with 81 patients were identified. Patients' Hurley stages included stage I (9.1%, 1/11), II (36.4%, 4/11), and III (54.5%, 6/11). The most extensively studied procedural interventions include negative pressure wound therapy (n = 30), surgical excision with skin graft/flap (n = 19), and endoscopic electrode or laser treatment (n = 11). In all, promising response rates for procedural management strategies were observed in the literature but the findings were largely based on case reports/series. Randomized controlled trials (RCTs), especially those geared toward minimally invasive procedural treatments, are needed to help guide clinicians on the most efficacious treatment modalities for pediatric patients with HS.