Emergency department sonography by emergency physicians

A retrospective study was conducted to examine whether emergency physicians can perform accurate ultrasonography that influences the diagnosis and treatment of selected disorders in the emergency department (ED). The physicians acquired a moderate level of expertise in sonography using a series of practical demonstrations and lectures. Patients with symptoms suggestive of cardiac, gynecologic, biliary tract, and abdominal vascular disease periodically underwent ED sonography. The initial interpretation was used as a diagnostic adjunct to subsequent therapy. The accuracy of positive sonographic findings was assessed by confirmatory testing, formal review, or confirmatory clinical course. Emergency physicians were able to diagnose correctly (1) the presence and approximate size of pericardial effusions, (2) the presence or absence of organized cardiac activity in patient with clinical electrical mechanical dissociation, (3) the presence or absence of intrauterine pregnancy in pregnant patients with lower abdominal/pelvic complaints, (4) the position of intrauterine devices in patients with suspected uterine perforation, (5) the presence of gallstones in patients with suspected biliary tract disease, and (6) the presence and size of abdominal aortic aneurysms in patients with pulsatile masses or unexplained abdominal pain. It was concluded that reliable sonography which influences diagnosis and therapy can be performed by emergency physicians and that sonography should become a standard procedure in EDs.     

Medikamentöse Therapie des Vorhofflimmerns in speziellen Situationen

The treatment of atrial fibrillation has to take into account the underlying cardiac and extracardiac diseases. A successful treatment of the underlying disease will only be sufficient treatment of atrial fibrillation in very rare situations. Therefore, this review focuses on the consequences of underlying heart disease, the hemodynamics and concomitant clinical situations on the treatment of atrial fibrillation.     

Whoonga and the Abuse and Diversion of Antiretrovirals in Soweto,South Africa

Media reports have described recreational use of HIV antiretroviral medication in South Africa, but little has been written about this phenomenon in the scientific literature. We present original, qualitative data from eight semi-structured interviews that characterize recreational antiretroviral use in Soweto, South Africa. Participants reported that antiretrovirals, likely efavirenz, are crushed, mixed with illicit drugs (in a mixture known as whoonga), and smoked. They described medications being stolen from patients and expressed concern that antiretroviral abuse jeopardized the safety of both patients and users. Further studies are needed to understand the prevalence, patterns, and consequences of antiretroviral abuse and diversion.     

High pre-transplant serum nitrate levels predict risk of acute steroid-refractory graft-versus-host disease in the absence of statin therapy

Steroid-refractory graft-versus-host disease is a life-threatening complication after allogeneic stem cell transplantation. Evidence is accumulating that steroid-refractory graft-versus-host disease is associated with endothelial distress. Endothelial cell homeostasis is regulated by nitric oxide, and serum nitrates are derived from nitric oxide synthase activity or dietary sources. In this retrospective study based on 417 patients allografted at our institution we investigated whether quantification of serum nitrates could predict steroid-refractory graft-versus-host disease. Elevated pre-transplant levels of serum nitrates (>26.5 μM) predicted steroid-refractory graft-versus-host disease (P=0.026) and non-relapse mortality (P=0.028), particularly in combination with high pre-transplant angiopoietin-2 levels (P=0.0007 and P=0.021, respectively). Multivariate analyses confirmed serum nitrates as independent predictors of steroid-refractory graft-versus-host disease and non-relapse mortality. Differences in serum nitrate levels did not correlate with serum levels of tumor necrosis factor or C-reactive protein or expression of inducible nitric oxide synthase in blood cells. Patients with high pre-transplant nitrate levels had significantly reduced rates of refractory graft-versus-host disease (P=0.031) when pravastatin was taken. In summary, patients at high risk of developing steroid-refractory graft-versus-host disease could be identified prior to transplantation by serum markers linked to endothelial cell function. Retrospectively, statin medication was associated with a reduced incidence of refractory graft-versus-host disease in this endothelial high-risk cohort.     

Disseminated coccidioidomycosis with peritonitis in a patient with acquired immunodeficiency syndrome. Prolonged survival associated with positive skin test reactivity to coccidioidin

Coccidioidomycosis involving the lungs and the meninges occurred as the sole opportunistic infection in a patient with the acquired immunodeficiency syndrome (AIDS). Skin test reactivity to coccidioidin was present, but antibody response to coccidioidal antigens was markedly distinguished. Treatment with amphotericin B, administered intravenously for 3 1/2 months and intrathecally for 13 months, resulted in a disease-free interval of one year. Subsequently, coccidioidal peritonitis developed, which responded to treatment with amphotericin B. However, 29 months after the initial diagnosis, the patient died of complications of hepatic encephalopathy resulting from alcoholic cirrhosis. To our knowledge, this patient represents the first reported case of coccidioidal peritonitis in AIDS and involves the most prolonged survival of a patient with coccidioidomycosis and AIDS. The presence of positive skin test reactivity to coccidioidin may have been a predictor of prolonged survival in this patient.     

Allogeneic stem cell transplantation in AML with t(6;9)(p23;q34);DEK-NUP214 shows a favourable outcome when performed in first complete remission

Acute myeloid leukaemia (AML) with t(6;9)(p23;q34) is a poor-risk entity, commonly associated with FLT3-ITD (internal tandem duplication). Allogeneic stem-cell tranplantation (allo-SCT) is recommended, although studies analysing the outcome of allo-SCT in this setting are lacking. We selected 195 patients with t(6;9) AML, who received a first allo-SCT between 2000 and 2016 from the EBMT (European Society for Blood and Marrow Transplantation) registry. Disease status at time of allo-SCT was the strongest independent prognostic factor, with a two-year leukaemia-free survival and relapse incidence of 57% and 19% in patients in CR1 (first complete remission), 34% and 33% in CR2 (second complete remission), and 24% and 49% in patients not in remission, respectively (P < 0·001). This study, which represents the largest one available in t(6;9) AML, supports the recommendation to submit these patients to allo-SCT in CR1.     

Artificial intelligence in liver ultrasound

Artificial intelligence (AI) is playing an increasingly important role in medicine, especially in the field of medical imaging. It can be used to diagnose diseases and predict certain statuses and possible events that may happen. Recently, more and more studies have confirmed the value of AI based on ultrasound in the evaluation of diffuse liver diseases and focal liver lesions. It can assess the severity of liver fibrosis and nonalcoholic fatty liver, differentially diagnose benign and malignant liver lesions, distinguish primary from secondary liver cancers, predict the curative effect of liver cancer treatment and recurrence after treatment, and predict microvascular invasion in hepatocellular carcinoma. The findings from these studies have great clinical application potential in the near future. The purpose of this review is to comprehensively introduce the current status and future perspectives of AI in liver ultrasound.     

Analysis of the envelope region of the highly divergent HIV-2ALT isolate extends the known range of variability within the primate immunodeficiency viruses.

HIV-2ALT is a highly divergent HIV-2-related isolate that is genetically equidistant to the prototypic HIV-2 strains, defined by HIV-2ROD, and to the simian immunodeficiency viruses SIVmac and SIVsm. We have now cloned and sequenced the envelope region of HIV-2ALT, thus completing the analysis of the whole viral genome. The sequences of env and nef and of the second exons of tat and rev were compared with those of the other viruses of the HIV-2/SIVsm/SIVmac group. Despite of the high degree of variation of HIV-2ALT, functional domains of the genes are conserved. Although in env, the overall pattern of constant and variable domains is maintained, many single amino acid exchanges exist at positions previously thought to be constant in HIV-2 strains. In addition, when compared with a broader spectrum of immunodeficiency viruses, which includes SIVMND from mandrill and SIVAGM from African green monkey, HIV-2ALT Env has a high percentage of amino acid exchanges, which are unique to this strain. This underlines the separate branch of HIV-2ALT within the phylogenetic tree and makes obvious the inclusion of such divergent strains in preventive and therapeutic programs.