Observations on the log human chorionic gonadotropin-time relationship in early pregnancy and its practical implications

In this study, we examined whether the doubling time of human chorionic gonadotropin is different at different stages of early pregnancy and whether the use of multiple nomograms for doubling time of human chorionic gonadotropin rather than a single critical value can improve the diagnosis of ectopic pregnancy. Forty-four women with intrauterine pregnancies who had abdominal pain and/or vaginal bleeding but who did not abort their pregnancies and 44 women with surgically proved ectopic pregnancies were studied. No difference was found in the doubling time of human chorionic gonadotropin when women were classified according to recently published criteria (Pittaway DE, Reish RL, Wentz AC. Doubling times of human chorionic gonadotropin increase in early viable intrauterine pregnancies. Am J Obstet gynecol 1985;152:299-302), and estimates of the doubling time of human chorionic gonadotropin were not influenced by the initial human chorionic gonadotropin values or the sampling interval used. In the human chorionic gonadotropin range of practical interest, multiple nomograms identified 26 of 33 (79%) women with ectopic pregnancy who had rising levels of human chorionic gonadotropin, whereas our previously reported criteria identified 28 of 37 (76%) cases. The false positive rate for each method was 9.7%. Seventeen (19%) of 88 patients could not be allotted to the human chorionic gonadotropin categories for which nomograms of the doubling time of human chorionic gonadotropin have been derived. We conclude that our previous recommendations for determining the rate of increase of human chorionic gonadotropin in serum from paired samples do not require revision at this time.     

Characteristics and predictors of treatment failure with intravenous tigecycline monotherapy among adult patients with severe Clostridioides (Clostridium) difficile infection: a single-centre observational cohort study

Our aim was to analyze characteristics of treatment failure with intravenous tigecycline monotherapy among adults with severe Clostridioides (Clostridium) difficile infection (CDI). A single-centre observational cohort study was performed between 2014 and 2018. Data were collected by charts review, diagnosis and severity were determined by ESCMID guidelines. Primary outcome was treatment failure, secondary outcomes were in-hospital mortality, relapse, colectomy, and complication rates. Independent predictors of failure were identified using logistic regression. Altogether 110 patients were included, failure occurred in 37.3%. Patients with failure frequently had chronic heart and pulmonary co-morbidities, peritonitis, higher CRP levels, ICU admittance rates and need for total parenteral nutrition and vasopressors. Mostly, CDI-specific mortality and complications contributed to failure. Relapse rates were similar. Chronic pulmonary disease, ileus, total parenteral nutrition, and duration of tigecycline therapy were predictors of failure. We conclude that severe CDI cases with higher risk for tigecycline monotherapy failure might be identified by contributing factors.     

An Exploratory Analysis of Gender as a Potential Modifier of Treatment Effect Among Patients in a Randomized Controlled Trial of Integrative Acupuncture and Spinal Manipulation for Low Back Pain

ObjectiveTo identify the potential association of self-reported gender on pain and disability among patients in a randomized controlled trial of integrative acupuncture and spinal manipulation therapy (SMT) for low back pain (LBP).MethodsIn the original study, 100 participants with LBP were randomized to receive acupuncture, SMT, or both combined. Eighty completed treatment and were followed for 60 days. Primary outcome measures were the Roland-Morris Disability Questionnaire and numeric pain scales. This study was a secondary analysis and used regression models to estimate and test for gender-specific differences in outcomes from baseline through end of treatment.ResultsWomen assigned to acupuncture averaged a 3.8-point reduction in highest LBP vs 2.0 points for SMT, whereas men assigned to SMT averaged a 3.5-point reduction vs 1.8 points for acupuncture (P for interaction = .04). There was a trend toward the same for disability (P for interaction = .12). For women, acupuncture alone led to better outcomes without SMT, and for men, SMT alone led to better outcomes without acupuncture. Women who received acupuncture were more likely to experience 50% or greater reductions in disability and pain, whereas men who received SMT were more likely to experience 50% or greater reductions in disability and pain.ConclusionAn association was found between self-reported gender and response to LBP treatment. Women demonstrated a greater reduction in pain and disability with acupuncture and men with SMT. Future clinical trials should consider sex as a potential determinant of treatment outcomes for LBP.     

Ochrobactrum anthropi-Caused Osteomyelitis in the Foot Mimicking a Bone Tumor: Case Report and Review of the Literature

Osteomyelitis due to Ochrobactrum anthropi, a new genus Ochrobacterum widely distributed in the environment and occasionally associated with human infection, has been described in only a few case reports. We present a report of an unusual case of osteomyelitis caused by O. anthropi that was identified 9 years after a nail puncture to the lateral cuneiform bone. The patient was an 18-year-old male with a painful foot lesion that had originally been misdiagnosed as an osteolytic tumor. He underwent surgery and 2 firm pieces of rubber measuring 7 and 10 mm were removed from the lower portion of the lateral cuneiform bone, which appeared to be affected by an infection. After surgical debridement, O. anthropi was isolated from the bone cultures. The patient was successfully treated with a 6-week course of oral ciprofloxacin and clindamycin. At 1 year after the corrected diagnosis and appropriate treatment, he was symptom free and had resumed regular activities and an athletic lifestyle.     

Ocular injuries following sulfur mustard exposure—Pathological mechanism and potential therapy

Sulfur mustard (SM) is a potent vesicant, known for its ability to cause incapacitation and prolonged injuries to the eyes, skin and respiratory system. The toxic ocular events following sulfur mustard exposure are characterized by several stages: photophobia starting a few hours after exposure, an acute injury phase characterized by inflammation of the anterior segment and corneal erosions and a delayed phase appearing following a clinically silent period (years in human). The late injury appeared in part of the exposed eyes, expressed by epithelial defects and corneal neovascularization (NV), that lead to vision deficits and even blindness. During the last years we have characterized the temporal development of ocular lesions following SM vapor exposure in rabbits and have shown the existence of two sub-populations of corneas, those exhibiting delayed ocular lesions (clinically impaired) and those exhibiting only minor injuries if at all (clinically non-impaired). The aim of the present study was to investigate the pathological mechanism underlying the delayed injury by focusing on the unique characteristics of each sub-population and to test the efficacy of potential treatments.     

Deficiencies of antithrombin, protein C and protein S - practical experience in genetic analysis of a large patient cohort

Deficiencies of natural anticoagulant proteins including antithrombin (AT), protein C (PC) and protein S (PS) are important causes of inherited thrombophilia. This study aimed to report on the practical experience gained in performing genetic analyses of a large cohort of patients with AT, PC and PS deficiencies and to relate this knowledge to clinical application. We genotyped a large cohort of 709 unrelated patients with AT (231), PC (234) and PS (244) deficiencies referred to us by physicians throughout Germany. Mutations were detected by direct sequencing and multiplex ligation-dependent probe amplification (MLPA). The highest mutation detection rate (MDR) was found for the SERPINC1 gene (83.5%), followed by the PROC (69%) and PROS1 (43%) genes. Even at AT activities close to the normal range (75%), the MDR was 70%. Contrastingly, for PC and PS deficiencies, the MDR dropped significantly and mildly lowered to subnormal values. At PS activities >55% for PS no mutations were detected. Mutation profiles of all three genes were similar with the highest prevalence for missense mutations (63-78%), followed by nonsense (7-11%), splice-site mutations (7-13%), small deletions (1-8%), small insertions/duplications (1-4%) and large deletions (3-6%). In conclusion, genetic testing is a useful diagnostic tool for diagnosing thrombophilia. Based on our data, genetic analysis for patients with AT deficiency is indicated for all subnormal activities. In contrast, genotyping is not advisable for PC activities >70% and for PS activities >55%.     

Transposition of great arteries is associated with increased carotid artery stiffness

Transposition of great arteries is the consequence of abnormal aorticopulmonary septation. Animal embryonic data indicate that septation and elastogenesis are related events, but human and clinical data are not available. We tested the hypothesis that large artery elastic function was impaired in patients with transposition of great arteries. We studied 34 patients aged 9 to 19 years, 12+/-3 years after atrial switch operation; 14 patients aged 7 to 9 years, 8+/-1 years after arterial switch operation; and 108 healthy control subjects matched for age. Carotid artery diastolic diameter and pulsatile distension were determined by echo wall-tracking; carotid blood pressure was measured by tonometry. Systolic pressure was higher and diastolic pressure was lower in patients than in controls. Patients with atrial and arterial switch repair were compared with their respective controls by 2-factor ANOVA. For patients with atrial switch repair versus control, stiffness index beta was 4.9+/-1.5 versus 3.1+/-1.0 (P<0.001); for patients witch arterial switch versus control, stiffness index beta was 3.8+/-1.1 versus 2.1+/-0.6 (P<0.001). Similar differences were observed for carotid compliance, distensibility, and incremental elastic modulus as well. The interaction term was not significant for any of the elastic variables, indicating that carotid stiffening was a characteristic of the condition and not the consequence of different hemodynamics. Carotid artery is markedly stiffer in patients, suggesting that impaired elastogenesis may constitute part of the congenital abnormality. Since carotid artery stiffness has been established as an independent cardiovascular risk factor, this condition may have consequences in the clinical management of these patients.     

Safe Zones for Cerclage Wiring of the Humeral Diaphysis

Cerclage wiring of the humeral diaphysis entails particular danger to the radial nerve and the deep brachial artery. We sought to delineate safe zones for minimally invasive cerclage wiring of the humeral diaphysis, specifically in relation to the radial nerve and accompanying vasculature. Cerclage wires were percutaneously inserted into three groups of fresh-frozen cadaveric humeri. Group 1—proximal midshaft humerus at 30% of humeral height (n = 4); Group 2—midshaft spiral groove at 45% of humeral height (n = 4); and Group 3—distal midshaft humerus at 60% of humeral height (n = 4). Subsequently, an extensive surgical exploration of the arteries and nerves around the humerus was performed, noting any disturbance to the vessels or nerves and measuring the distance from the cerclage wire to the radial nerve. Neurovascular structures were injured in 75% of specimens when the cerclage wire was inserted at the level of the spiral groove. Both posterior structures, e.g. the radial nerve and the deep brachial artery, and medial structures, e.g., the median nerve and brachial artery, were incarcerated. Application of the cerclage at 30% or 60% of humeral height did not cause neurovascular injury. Minimally invasive application of the cerclage wire at the spiral groove, which is at 45% of humeral height, is likely to cause injury to neurovascular structures. Application of the cerclage at the proximal or distal midshaft humeral areas is associated with less risk of such injury. Clin. Anat. 33:552–557, 2020. © 2019 Wiley Periodicals, Inc.