A multicentric study of the disease risks and first manifestations in hereditary transthyretin amyloidosis (ATTRv): insights for an earlier diagnosis

BACKGROUND

In hereditary transthyretin amyloidosis (ATTRv), early manifestation and age at onset (AO) may vary strikingly. We assessed the disease'risk (penetrance), AO and initial features in ATTRv families to gain insights on the early disease presentation.

METHODS

Genealogical information, AO and first disease manifestations were collected in ATTRv families, from Sweden, Italy (Sicily), Spain (Mallorca), France, Turkey, Brazil. Penetrance was computed using a non-parametric survival method.

RESULTS

We analysed 258 TTRV30M kindreds and 84 carrying six other variants (TTRT49A, F64L, S77Y, S77F, E89Q, I107V). In ATTRV30M families, the earliest disease risk was found at age 20 years in the Portuguese and Mallorcan families and at age 30-35 years, in the French and Swedish groups. The risks were higher in men and in carriers of maternal descent. In families carrying TTR-nonV30M variants, the earliest disease risk ranged from 30 y-o in TTRT49A to 55 y-o in TTRI107V families. Peripheral neuropathy symptoms were the most frequent initial manifestations. Among patients carrying TTRnonV30M variants, about 25% had an initial cardiac phenotype, one third a mixed phenotype.

CONCLUSION

Our work provided solid data on the risks and early features of ATTRv in a spectrum of families to enhance an early diagnosis and treatment.

Prevalence and clinical characteristics of pulmonary TB among pregnant and post-partum women

SETTING: Antenatal care (ANC) and postpartum care (PPC) clinic in Manhiça District, Mozambique.OBJECTIVE: To estimate the prevalence of TB among pregnant and post-partum women and describe the clinical characteristics of the disease in a rural area of Southern Mozambique.METHODS: We conducted a cross-sectional TB prevalence study among pregnant and post-partum women recruited from September 2016 to March 2018 at the Manhiça Health Care Center (MHC). We recruited two independent cohorts of women consecutively presenting for routine pregnancy or post-partum follow-up visits.RESULTS: A total of 1,980 women from the ANC clinic and 1,010 from the PPC clinic were enrolled. We found a TB prevalence of 505/100,000 (95% CI: 242-926) among pregnant women and 297/100,000 (95% CI: 61-865) among post-partum women. Among HIV-positive pregnant women, TB prevalence was 1,626/100,000 (95% CI: 782-2,970) and among postpartum HIV-positive women, TB prevalence was 984/100,000 (95% CI: 203-2,848).CONCLUSIONS: The burden of TB was not higher in postpartum women than in pregnant women. Most TB cases were detected in HIV-positive women. TB screening and diagnostic testing among pregnant and postpartum women attending ANC and PPC clinics in Manhiça District is acceptable and feasible.

SURGICAL AND PROGNOSTIC IMPLICATIONS IN GASTRIC ADENOCARCINOMA BY THE INTEGRATION OF PROTEOMIC MOLECULAR ANALYSIS

INTRODUCTION

Despite a steady decline in the incidence of gastric cancer (GC) over recent decades, the prognosis remains poor with 5-year survival rates of 21.9% in Europe. The AJCC Cancer Staging Manual (8th Edition) establishes the necessity to evaluate personalized survival models. These models would help in the decision-making process. Proteomic and genomic molecular analyses have provided a more in-depth knowledge of GC.

MATERIAL AND METHODS

19 patients affected by 21 tumors operated between 2012-2014 were prospectively included. Healthy tissue and tumor samples were taken from each case and deposited in a tissue biobank for subsequent proteomic analysis by Proteomics Department.

RESULTS

The following histopathological types were identified: (73.69%) intestinal, (10.52%) diffuse, and (15.78%) undetermined, poorly differentiated, and mixed neuroendocrine of the classification WHO. According to the size and extent of tumor invasion, the percentages of the sample were T1 or T2 (26.31%) and T3 or T4 (73.68%). Furthermore, 57.89% of the patients were found to have lymph-node metastases (N 1, 2, 3 +). After the differences in protein intensities in healthy tissue and tumor tissue were analyzed, it was found that in the healthy tissue, EGFR1, MAPK1 and MAPK3 were predictive variables of overall survival when the tumor stage was T3 or T4

CONCLUSIONS

It would be convenient to redefine the classification and treatment plan in gastric cancer by integrating the study at a molecular level.

Anticipation on age at onset in kindreds with hereditary ATTRV30M amyloidosis from the Majorcan cluster

BACKGROUND

Hereditary transthyretin amyloidosis (ATTRV30M) is a rare disease caused by amyloid deposition and characterized by a heterogeneous presentation. Anticipation (AC) is described as the decrease in age at onset (AO) within each generation. Our aim was to study AC in a large number of ATTRV30M kindred from Majorca (Spain), and gain further insight into parent-of-origin effects.

METHODS

In a cohort of 262 subjects with ATTRV30M amyloidosis belonging to 51 families, we found 37 affected pairs. AO is defined as the age at the first symptom and AC (parent's age at disease onset minus that of the offspring) were calculated. Chi-square test, independent t-test and paired t-test were used for comparisons between groups. Association between AO of parents and offsprings were assessed by Pearson's correlation coefficient.

RESULTS

Offspring mean AO was 16 years lower than that of the parents (p < .001) regardless of the sex of the parents and the offspring. AC occurred in 31 out of the 37 pairs, with no differences related to the sex of parents or offspring. There was a moderate correlation (r = 0.49; p < .001) between AO of the parents and that of the offsprings.

CONCLUSION

AC was no uncommon in our cohort, and AO tended to decrease in successive generations.

An evidence-based bundle improves the quality of care and outcomes of patients with candidaemia

Background

Candidaemia is a leading cause of bloodstream infections in hospitalized patients all over the world. It remains associated with high mortality.

Objectives

To assess the impact of implementing an evidence-based package of measures (bundle) on the quality of care and outcomes of candidaemia.

Methods

A systematic review of the literature was performed to identify measures related to better outcomes in candidaemia. Eight quality-of-care indicators (QCIs) were identified and a set of written recommendations (early treatment, echinocandins in septic shock, source control, follow-up blood culture, ophthalmoscopy, echocardiography, de-escalation, length of treatment) was prospectively implemented. The study was performed in 11 tertiary hospitals in Spain. A quasi-experimental design before and during bundle implementation (September 2016 to February 2018) was used. For the pre-intervention period, data from the prospective national surveillance were used (May 2010 to April 2011).

Results

A total of 385 and 263 episodes were included in the pre-intervention and intervention groups, respectively. Adherence to all QCIs improved in the intervention group. The intervention group had a decrease in early (OR 0.46; 95% CI 0.23–0.89; P = 0.022) and overall (OR 0.61; 95% CI 0.4–0.94; P = 0.023) mortality after controlling for potential confounders.

Conclusions

Implementing a structured, evidence-based intervention bundle significantly improved patient care and early and overall mortality in patients with candidaemia. Institutions should embrace this objective strategy and use the bundle as a means to measure high-quality medical care of patients.

Significance of the isolation of Staphylococcus aureus from a central venous catheter tip in the absence of concomitant bacteremia: a clinical approach

The optimal approach following the isolation of Staphylococcus aureus from an intravascular catheter tip in the absence of concomitant bacteremia remains unclear. We aimed to determine the rate of delayed complications in these patients. We performed a retrospective observational study (during the period 2002-2012) including patients with a catheter tip culture yielding S. aureus. Patients were followed up for ≥6 months. The primary endpoint was the occurrence of delayed staphylococcal complications (either bacteremia and/or metastatic distant infections). A total of 113 patients were included (75 % male, median age 61 years): 46 and 67 with negative and positive blood cultures, respectively. We found a lower rate of delayed staphylococcal complications in cases with no bacteremia within 48 h since catheter removal than in cases of confirmed S. aureus catheter-related bacteremia (0.0 % vs. 25.4 %; p-value < 0.001). In the group without bacteremia, there was a subgroup of 15 patients (32.6 %) who did not receive antimicrobial treatment. Again, delayed complications occurred less commonly in this subgroup of patients without bacteremia (0.0 % vs. 25.4 %; p-value = 0.033). In contrast to patients with S. aureus catheter-related bacteremia, no delayed infectious complications were observed in patients with an isolated catheter tip culture yielding S. aureus and negative blood cultures within 48 h of catheter removal. Futures studies are needed to assess if the therapeutic approach could be different for this group of patients.

[Cytomegalovirus sensitivity to anti-retroviral agents in patients infected with the human immunodeficiency virus with chorioretinitis in Spain]

OBJECTIVES

To determine the prevalence of the in vitro resistance rate of cytomegalovirus (CMV) to gancyclovir (GCV) and foscarnet (FOS) among patients with AIDS and chorioretinitis. Furthermore, in vitro sensitivity results were compared with the clinical response to therapy.

PATIENTS AND METHODS

Thirty-six patients with the diagnosis of CMV retinitis and AIDS were included in the study. Antiviral sensitivity testing was performed to 51 clinical CMV strains from these patients. The in vitro sensitivity was compared with the clinical response to therapy. The resistance criteria were the inhibitory dose50 (ID50) GCV > 5 M and ID50 FOS > 400 M.

RESULTS

None of the CMV tested strains was resistant to GCV or FOS; however, six patients who had relapses of chorioretinitis while on maintenance therapy and isolation during the condition had mean ID50 of strains (n=8) of 1,95 M for GCV (standard deviation [SD] of 0.71) and 115.2 for FOS (SD, 34.7). These patients responded well when drugs were used at induction doses.

CONCLUSION

The in vitro sensitivity testing is not a good predictor of infection control when the drug is used at maintenance doses. This suggests that these strains should be classified in the intermediate resistant category.

[Should cefminox substitute cefoxitin in infections caused by bacteria susceptible to both drugs?]

We studied the in vitro activity of cefminox (MIC by agar dilution) and cefoxitin against 477 facultative Gram-positive and Gram-negative isolates which were recovered from clinical specimens and identified by standard methods. Cefminox has proved to be 4-16 times more active than cefoxitin against enteric Gram-negative bacilli commonly involved in cholecystitis, secondary peritonitis, intraabdominal abscesses and gynecological infections. On the contrary, cefoxitin has proved to be four times more active against Gram-positive cocci. Both have been ineffective against Enterobacter spp., Pseudomonas aeruginosa and Acinetobacter spp. The microbiological activity and pharmacokinetic parameters of cefminox make it one of the first choice treatments for community-acquired intraabdominal and pelvic infections with the presence of anaerobes.

Sertaconazole in the treatment of pediatric patients with cutaneous dermatophyte infections

Sertaconazole is a new topical anti-mycotic with demonstrated efficacy against dermatophyte infections in adults. An open-label, multicenter study was conducted to assess the efficacy and tolerability of sertaconazole in children in primary care. Twenty-nine children were initially included in the study and tolerability was assessed in all of them. The 16 children examined for efficacy (8 girls and 8 boys, aged 2 to 16 years) all had culture-confirmed cutaneous mycoses. Fourteen children had tinea corporis, 1 had tinea cruris, and 1 had tinea pedis. Microsporum canis was identified in 50% of cultures and Trichophyton rubrum in 42%. Patient lesions were treated with 2% sertaconazole cream during a 2-week period. Clinical cure was achieved in 31% of patients after 1 week, 75% after 2 weeks, and 100% after 4 weeks. No local or systemic adverse effects were observed. It is concluded that once-daily topical sertaconazole is an effective and well-tolerated treatment for pediatric patients with dermatophytosis.

[Mediterranean boutonneuse fever in children. Study of 139 cases]

A prospective study of 139 children suffering mediterranean spotted fever, all of them hospitalized during the summer time of the last five years is presented. Clinical features were high fever, maculopapulous rash and black eschar ("tàche noire"). Among analytical findings, leucocyte count was decreased in a 38.8% of children during the first week of illness. Weil-Felix test was positive in 47.2% for OX-2 and 52.7% for OX-19 of cases. The indirect immunofluorescence for rickettsial conorii was positive in 100% of cases in the second determination. 74.1% of patients received antimicrobial therapy and 25.9% symptomatic treatment. All children cured without complications.