A novel approach to evaluating the benefit of post-urinary tract infection renal ultrasonography,using decision curve analysis

Background

The benefit of post-urinary tract infection (UTI) sonography to detect clinically significant renal abnormalities remains a subject open to debate. Decision curve analysis (DCA) is a novel method for evaluating the clinical usefulness of diagnostic tests. Our objective was to determine, using DCA, the benefit of post-UTI sonography and of post-UTI sonography with biological markers of inflammation to predict the risk of recurrence of febrile UTI in children aged 2 to 24 months without known uropathy.

Methods

We retrospectively analyzed all children aged 2 to 24 months, without known uropathy, who presented with a first episode of febrile UTI between 2009 and 2012 and followed them for 30 months. We then used DCA to estimate the benefit of post-UTI sonography or post-UTI sonography + biological markers of inflammation for detecting the risk of recurrence.

Results

A total of 318 children [144 boys (45.3 %) and 174 girls (54.7 %)], with a mean age of 6.9?±?5.6 months, were identified. Of these, 210 children presented with a significant inflammation [66.2 %; 95 % confidence interval (CI) 61.0–71.4], and 30 (9.4 %; 95 % CI 6.2–12.6) presented with abnormal post-UTI sonographic findings. Eighteen (5.7 %; 95 % CI 3.1–8.2) children presented with recurrent UTI at 30 months.

Conclusions

There were significantly more recurrences in those children who presented with abnormal sonographic findings than in those who did not (relative risk?7.68; 95 % CI 3.03–19.46). However, taking into account the effect of false-positives and false negatives, the DCA revealed that for threshold probabilities of >30 %, at which patients/doctors are concerned about unnecessary interventions (whether tests or treatments), neither post-UTI sonography nor post-UTI sonography + biological markers of inflammation have sufficient value to improve care.

     

Bariatric Surgery in Obese Patients with Type 1 Diabetes: Effects on Weight Loss and Metabolic Control

Background

Type 1 diabetes patients, although typically lean, experience an increased prevalence of obesity, and bariatric surgery is considered in severe cases. Bariatric surgery in such patients leads to significant weight loss and decreased insulin requirements; however, effects on glycemic control remain discussed. We assessed, in obese patients with type 1 diabetes, the effects of bariatric surgery upon body weight, body composition, and glycemic control, including the occurrence of hypoglycemic events.

Methods

Thirteen obese patients with type 1 diabetes who underwent bariatric surgery (Roux-en-Y gastric bypass n?=?6, sleeve gastrectomy n?=?7) were matched with obese patients without diabetes and with type 2 diabetes patients during 12 months of follow-up. Outcomes included body weight, DXA-assessed body composition, HbA1c, and incidence of hypoglycemia.

Results

At 12 months, median surgery-induced weight loss was 27.9 % (21.1–33.3), 26.1 % (24.8–29.7), and 27.5 % (21.8–32.1) in patients with type 1 diabetes, type 2 diabetes, and without diabetes, respectively, with no significant differences across the groups. Similar findings were observed for body fat changes. At 12 months, median HbA1c decreased from 8.3 to 7.6 % in type 1 diabetes patients versus 8.0 to 5.9 % in type 2 diabetes patients (P?=?0.04 between the groups). In type 1 diabetes patients, the number of reported minor hypoglycemia increased transiently only at 6 months. Two patients reported severe hypoglycemia (one episode each).

Conclusions

Type 1 diabetes patients benefit from bariatric surgery in terms of weight loss and glycemic control. Close monitoring of insulin therapy appears warranted to prevent minor hypoglycemia in the first months post-surgery.

     

Nasal natural killer/T-cell lymphoma and its association with type "i"/XhoI loss strain Epstein-Barr virus in Chile

BACKGROUND: Nasal T/natural killer (NK)-cell lymphoma is an aggressive type of non-Hodking's lymphoma associated with Epstein-Barr virus (EBV) and striking geographical variations worldwide. AIM: To characterise nasal NK/T-cell lymphoma associated with genotypes of EBV in Chile, a Latin American country, where multiple strains of EBV, including two new recombinant strains, in healthy individuals were recently found. METHODS: Cases with diagnosis of primary nasal lymphoma were selected for histological and immunohistochemical analysis (CD3, CD3e, CD4, CD8, CD79a, CD56, CD57 and TIA-1) and in-situ hybridisation, serology and genotyping analysis for EBV. RESULTS: Out of 22 cases, 9 (41%) cases fulfilled the World Health Organization criteria for nasal NK/T-cell lymphoma; of these 7 (78%) cases were positive for EBV. Genotyping analysis revealed 6 cases of type 1 EBV and wildtype F at the BamHI-F region, 4 cases type "i" EBV at the BamHI-W1/I1 region; XhoI wild type was found in 2 and XhoI loss in 4 cases, respectively. Cosegregation analysis of the BamHI-W1/I1 region and XhoI restriction site showed the new recombinant strain type "i"/XhoI loss in 3 cases and type "i"/XhoI wild-type strain in 1 case. Most patients were treated with combined anthracycline-containing regimens. Half of the cases attained complete remission. CONCLUSION: Although nasal NK/T-cell lymphomas from Chile share similar clinicopathological features, high association with EBV and unfavourable prognosis with those described elsewhere, genotype analysis shows that the new recombinant type "i"/XhoI loss strain might contribute to explain the intermediate incidence of nasal NK/T-cell lymphomas in Latin America.     

Dolosigranulum pigrum causing nosocomial pneumonia and septicemia

We report a case of non-ventilator-associated nosocomial pneumonia and septicemia due to Dolosigranulum pigrum, a rare gram-positive opportunistic pathogen. The organism was isolated from bronchoalveolar lavage fluid and blood of a debilitated patient. D. pigrum was identified after 16S rRNA gene sequencing.     

Doppler and valvular prostheses

The principle of examination of prosthetic valves is not different from that of the original valves in terms of bioprosthesis. On the contrary, mechanical prosthesis are markedly opaque to ultrasounds and cause masking and non-flow phenomena behind the prosthesis, which are capable to completely hide abnormal retrograde flows, in traditional views (Apical 4 cavities to demonstrate a mitral leakage). Therefore, with mechanical prostheses, it is necessary to "cheat" and use atypical views which avoid interposition of the prosthesis between the ultrasound beam and the abnormal flow. The function of the prosthesis is evaluated on the following parameters: maximum transprosthetic velocity, maximum instant gradient, mean gradient and functional prosthetic area derived either from T1/2 or from the application of the continuity equation. The main factors of transprosthetic Max. V and gradients are the type and size of the prosthesis, the age of the prosthesis is only a factor for bioprostheses, and the cardiac rate and output. The golden rule is therefore to record, one month after the procedure, the Doppler characteristics of any new prosthesis, the patient being his own reference, year after year. Finally the characteristic manifestations of various dysfunctions are presented.     

Infarction with angiographically normal coronary vessels. (20 cases)

Over 8 years, 20 cases of infarction with normal coronary angiography have been reported, representing 0.9% of the patients who underwent a coronary angiography after a myocardial infarction. The main characteristics of these patients are compared with those taken from the literature. The occurrence of this disease mainly depends on the age: especially higher when the patients are younger, ranging between 1 and 4% in major series, but it may reach 25% in case of infarction occurring before the age of 30. Therefore, this entity mainly affects young patients (mean age in the literature: 34.3 years), with a large proportion of women (27%). The main risk factor is smoking, found in 3 out of 4 men an more than half of the women; on the contrary, hypercholesterolemia and arterial hypertension are only seldom found. In women, administration of estro-progestative medications in mentioned in almost every other case. Coronary heredity is mentioned in one out of 3 cases. In 68% of the cases, the infarction is the original manifestation and frequently occurs during stress: 60 p. cent of the cases. The site of the necrosis is insignificant. Mortality is low: 2 p. cent but in 5 p. cent of the cases, the course may be complicated by recurrence or heart failure. According to recent findings on coronary angiography during the acute phase, the pathogenesis could involve an arterial coronary thrombosis, perhaps developing on minimal coronary lesions, caused by a spasm and/or a platelets hyperaggregation; then this coronary thrombosis is revascularized.