Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations

OBJECTIVE

To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED).

STUDY DESIGN

Prospective study of children 2-18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7-10 days after discharge.

RESULTS

564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes.

CONCLUSIONS

Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.

Progression pattern and post-progression survival following atezolizumab and bevacizumab treatment in advanced hepatocellular carcinoma

BACKGROUND

Although the combination of atezolizumab and bevacizumab (ATZ + BEV) is a standard treatment for advanced hepatocellular carcinoma (HCC), strategies for addressing treatment failure and prognostic factors of post-progression survival (PPS) remain unestablished.

METHODS

We conducted a multicentre retrospective study to evaluate PPS following ATZ + BEV treatment in patients with advanced HCC. We classified the patients into three groups: BCLC stage B and BCLC stage C without or with new extrahepatic lesions (BCLCp-C1 and BCLCp-C2, respectively) at the time of progression.

RESULTS

Of the 204 patients who started ATZ + BEV treatment between October 2020 and September 2022, 110 showed disease progression, with 33, 55 and 22 showing the BCLCp-B, BCLCp-C1 and BCLCp-C2 stages of the disease, respectively. Specifically, patients with the BCLCp-B stage of the disease showed better overall survival than those with the BCLCp-C1 and BCLCp-C2 stages (hazard ratios: 1.93 [95% confidence interval, CI, 1.06-3.51] and 2.64 [95% CI, 1.32-5.30] for HCC stages BCLCp-C1 and BCLCp-C2, respectively). Via multivariable analysis, we identified the BCLCp-C1 and BCLCp-C2 stages, as well as performance status, Child-Pugh class and alpha-fetoprotein as poor prognostic factors for PPS.

CONCLUSIONS

BCLCp-B1 stage was identified as a better prognostic factor for PPS following ATZ + BEV treatment compared with BCLCp-C1 and BCLCp-C2 stages. This may help in making decisions regarding subsequent treatment after ATZ + BEV.

Evaluation of photoactivated chromophore for keratitis-corneal cross-linking (PACK-CXL) in feline infectious keratitis-patient demographics, treatment protocols, risk factors, and treatment outcome: a retrospective study

OBJECTIVES

To describe patient demographics and treatment protocols in a population of feline patients undergoing photoactivated chromophore for keratitis-corneal cross-linking (PACK-CXL) as an adjunctive treatment for infectious keratitis. Furthermore, to determine the proportion of PACK-CXL treatment success in the population studied, explore risk factors for treatment failure, and provide recommendations for future PACK-CXL clinical studies.

MATERIALS AND METHODS

Records from four veterinary ophthalmology practices were reviewed to identify eligible patients and extract data. Recorded variables included patient-related factors, ocular examination findings, PACK-CXL protocol parameters, and treatment outcome.

RESULTS

Records for 153 cats (154 eyes) were included. Median age in the treatment success group was 8 years (interquartile range (IQR) 4-12), with a median ulcer depth of 30% (IQR 30-40). Median age in the treatment failure group was 10.5 years (IQR 4.75-12) with a median ulcer depth of 45.9% (IQR 30-75). Persian cats were the most represented brachycephalic breed (52 out of 64 cats). Modified PACK-CXL protocols were used, including fast energy delivery (134 eyes), and increased fluence (52 eyes). The overall proportion of success was 88% (95% CI 84-93), which was variable between clinics. Eighty-two of 89 mesocephalic cat eyes (92%), and 54 of 65 brachycephalic cat eyes (83%) were classified as treatment successes.

CONCLUSIONS

PACK-CXL appeared to be a useful, adjunctive therapeutic modality for the treatment of infectious keratitis in the feline patient population presented here. Brachycephalic cats, older cats, and those with deeper ulcers may be at increased risk for treatment failure.

Innate biosignature of treatment failure in human cutaneous leishmaniasis

The quality and magnitude of the immune and inflammatory responses determine the clinical outcome of Leishmania infection, and contribute to the efficacy of antileishmanial treatments. However, the precise immune mechanisms involved in healing or in chronic immunopathology of human cutaneous leishmaniasis (CL) are not completely understood. Through sequential transcriptomic profiling of blood monocytes (Mo), neutrophils (Nφ), and eosinophils (Eφ) over the course of systemic treatment with meglumine antimoniate, we discovered that a heightened and sustained Type I interferon (IFN) response signature is a hallmark of treatment failure (TF) in CL patients. The transcriptomes of pre-treatment, mid-treatment and end-of-treatment samples were interrogated to identify predictive and prognostic biomarkers of TF. A composite score derived from the expression of 9 differentially expressed genes (common between Mo, Nφ and Eφ) was predictive of TF in this patient cohort for biomarker discovery. Similarly, machine learning models constructed using data from pre-treatment as well as post-treatment samples, accurately classified treatment outcome between cure and TF. Results from this study instigate the evaluation of Type-I IFN responses as new immunological targets for host-directed therapies for treatment of CL, and highlight the feasibility of using transcriptional signatures as predictive biomarkers of outcome for therapeutic decision making.

Time to Treatment Failure and Its Predictors Among Second-Line ART Clients in Amhara Region, Ethiopia: A Retrospective Follow-Up Study

Background

Second-line antiretroviral treatment failure has become a major public health issue, and the time to treatment failure among second-line ART clients varies globally, and the Sub-Saharan African region having a high rate of second-line ART treatment failures. In addition, after the ART treatment guideline changed there is limited information on Ethiopia. Therefore, this study aimed to assess time to treatment failure and its determinants among second-line ART clients in Amhara Region, Ethiopia.

Methods

A multi-centered retrospective follow-up study was conducted. A random sample of 860 people on second-line ART was selected by using a computer-generated simple random sampling technique from January 30, 2016, to January 30, 2021, at the University of Gondar Compressive Specialized Hospital, Felege Hiwot Compressive Specialized Referral Hospital, and Debre Tabor Compressive Specialized Referral Hospital, in Amhara region, Ethiopia. Data was captured using a checklist.

Results

A total of 81 (9.4%) ART clients developed second-line treatment failure, with a median follow-up time of 29 months with an interquartile range (IQR: 18, 41]. The risk of second-line treatment failure is higher among patients aged 15 to 30 years (adjusted hazard ratio (AHR) = 2.01, 95% confidence interval (CI): [1.16, 3.48]). Being unable to read and write (AHR = 1.312, 95% CI: [1.068, 1.613]), and poor ART drug adherence (AHR = 3.067, 95% CI: [1.845, 5.099]) were significant predictors of second-line ART treatment failures.

Conclusion

In the current study, the time to second-line ART treatment failure was high compared with a previous similar study in Ethiopia. Factors like being younger age, ART clients who are not being able to read and write, and having poor ART drug adherence was significant predictors of second-line ART treatment failure.

Early Reduction in C-Reactive Protein Following Treatment for Spinal Epidural Abscess: A Potential Treatment Guide

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

To assess the predictive value of early C-reactive protein (CRP) trends following diagnosis of spinal epidural abscess (SEA). Non-operative management with intravenous antibiotics has not demonstrated equivalent outcomes with regard to mortality and morbidity. Knowledge of specific patient and disease factors associated with worse outcomes may predict treatment failure.

METHODS

All patients treated for spontaneous SEA in a tertiary centre in New Zealand over a 10-year period were followed for at least 2 years. CRP at diagnosis and day 4-5 following treatment initiation was analyzed to determine predictors of CRP reduction of at least 50%. Proportional Cox hazards regression investigated mortality over 2 years.

RESULTS

94 patients met inclusion criteria and with CRP values available for analysis. Median age was 62 years (+/- 17.7) and 59 (63%) were treated operatively. Kaplan-Meier analysis estimate of 2-year survival was .81 (95% CI .72-.88). CRP reduction by 50% was seen in 34 patients. Patients who did not experience a 50% reduction were more likely to have thoracic infection (27 vs 8, P = .02) or multifocal sepsis (41 vs 13, P = .002). Failure to achieve a 50% reduction by day 4-5 was associated with worse post-treatment Karnofsky scores (70 vs 90, P = .03) and longer hospital stay (25 days vs 17.5 days, P = .04). Cox regression model showed mortality predicted by Charlson Comorbidity Index, thoracic location of infection, pre-treatment Karnofsky score, and failure to achieve a 50% CRP reduction by day 4-5.

CONCLUSIONS

Patients who fail to reduce CRP values by 50% at day 4-5 following treatment initiation are more likely to experience prolonged hospital stay, have poorer functional outcome and have greater mortality risk at 2 years. This group has severe illness regardless of treatment type. Failure to achieve a biochemical response to treatment should prompt reassessment.

Impact of residual skin lesions and previous biologic treatment failure on patient-reported outcomes in patients with psoriasis receiving biologic treatment

Recent advances in biologic treatments have made clear skin a realistic treatment goal for psoriasis. However, clear skin may not uniformly translate to an absence of impact on patients' quality of life. This retrospective observational study aimed to elucidate the factors influencing patient-reported outcomes in patients with psoriasis who have demonstrated successful clinician-reported outcomes on using biologics. A total of 96 patients who have achieved a ≥75% improvement in Psoriasis Area and Severity Index (PASI) scores with ≥6 months of biologic treatment were included. Their median PASI score was 0.4, with 37.5% having achieved PASI 100 (clear skin). Furthermore, 47.9% reported no impact of psoriasis on their quality of life (Dermatology Life Quality Index [DLQI] score 0 or 1), while 52.1% reported a negative impact (DLQI score ≥2). Notably, 28.1% of the participants had a history of biologic treatment failure, defined as the inability to achieve or sustain a 75% PASI improvement with the previously used biologic agent. Multivariable logistic regression analysis revealed a positive association between achieving PASI 100 and reporting no impact of psoriasis on quality of life (adjusted odds ratio [aOR] 3.88, 95% confidence interval [CI] 1.49-10.91, P = 0.007). Conversely, prior biologic treatment failure was negatively associated with reporting no impact of psoriasis on quality of life (aOR 0.13, 95% CI 0.02-0.65, P = 0.023). Furthermore, among patients with clear skin, those with experience of previous biologic treatment failure reported significantly lower quality of life than those without such experience (P = 0.033). In conclusion, minimal residual skin lesions and prior biologic treatment failure were associated with poorer patient-reported outcomes in patients with psoriasis. Opting for a biologic agent with the highest predicted efficacy, rather than pursuing a "step-up" approach with a higher possibility of treatment failure, may be a more suitable strategy in the biologic treatment of psoriasis.

Impact of headache frequency and preventive treatment failure on quality of life, disability, and direct and indirect costs among individuals with episodic migraine in the United States

OBJECTIVE

To evaluate unmet needs among individuals with episodic migraine (EM) in the United States (US).

BACKGROUND

Data are limited on the impact of headache frequency (HF) and preventive treatment failure (TF) on the burden of migraine in the US.

METHODS

A retrospective, cross-sectional analysis of 2019 National Health and Wellness Survey (NHWS) data was conducted from an opt-in online survey that identified respondents (aged ≥18 years) in the US with self-reported physician-diagnosed migraine. Participants were stratified by HF (low: 0-3 days/month; moderate-to-high: 4-14 days/month) and prior preventive TF (preventive naive; 0-1 TF; ≥2 TFs). Comparisons were conducted between preventive TF groups using multivariable regression models controlling for patient demographic and health characteristics.

RESULTS

Among individuals with moderate-to-high frequency EM, the NHWS identified 397 with ≥2 TFs, 334 with 0-1 TF, and 356 as preventive naive. The 36-item Short-Form Health Survey (version 2) Physical Component Summary scores were significantly lower among those with ≥2 TFs, at a mean (standard error [SE]) of 41.4 [0.8] versus the preventive-naive 46.8 [0.9] and 0-1 TF 44.5 [0.9] groups; p < 0.001 for both). Migraine Disability Assessment Scale scores were significantly higher in the ≥2 TFs, at a mean (SE) of 37.7 (3.9) versus preventive-naive 26.8 (2.9) (p < 0.001) and 0-1 TF 30.1 (3.3) (p = 0.011) groups. The percentages of time that respondents experienced absenteeism (mean [SE] 21.6% [5.5%] vs. 13.4% [3.6%]; p = 0.022), presenteeism (mean [SE] 55.0% [8.3%] vs. 40.8% [6.5%]; p = 0.015), overall work impairment (mean [SE] 59.4% [5.6%] vs. 45.0% [4.4%]; p < 0.001), and activity impairment (mean [SE] 56.8% [1.0%] vs. 44.4% [0.9%]; p < 0.001) were significantly higher in the ≥2 TFs versus preventive-naive group. Emergency department visits (preventive-naive, p = 0.006; 0-1 TF, p = 0.008) and hospitalizations (p < 0.001 both) in the past 6 months were significantly higher in the ≥2 TFs group. Direct and indirect costs were significantly higher in the ≥2 TFs (mean [SE] $24,026 [3460]; $22,074 [20]) versus 0-1 TF ($10,897 [1636]; $17,965 [17]) and preventive-naive ($11,497 [1715]; $17,167 [17]) groups (p < 0.001 for all). Results were similar in the low-frequency EM group.

CONCLUSIONS

In this NHWS analysis, individuals with more prior preventive TFs experienced significantly higher humanistic and economic burden regardless of HF.

Bone loss after discontinuation of denosumab: the devil is in the details

A 47-year-old postmenopausal woman with osteoporosis was treated with denosumab, which was discontinued due to side effects. She was therefore transitioned to a yearly intravenous infusion of zoledronic acid. An increase in bone turnover markers together with bone loss at the lumbar spine was observed before the second infusion, suggesting an overshooting of bone resorption due to denosumab discontinuation. On physical examination, the patient was restless and reported having lost about 10 kg since the last visit. A solitary left inferior thyroid nodule was noted on neck palpation. Circulating thyroid hormone levels were elevated, with suppressed thyroid-stimulating hormone. A thyroid scan showed increased uptake in the left inferior nodule with suppression of the remainder of the thyroid gland. A diagnosis of hyperthyroidism due to toxic adenoma was made. The patient was treated with radioactive iodine ablation, with consequent complete normalization of thyroid function. She continued yearly treatment with zoledronic acid. She remained clinically well with no further fractures. Bone turnover markers were appropriately suppressed and bone mineral density increased in the spine and hip. This case illustrates how the overshooting phenomenon following denosumab discontinuation may be compounded by the development of secondary conditions, which can result in suboptimal response to antiresorptive osteoporosis medications.

Treatment failure of Helicobacter Pylori in primary care

BACKGROUND

Due to increasing antibiotic resistance, the worldwide efficacy of Helicobacter pylori (Hp) eradication treatment has decreased.

AIM

To determine antimicrobial resistance of Hp in primary care.

DESIGN & SETTING

Retrospective cohort study using real-world routine health care data from 80 general practices in the Netherlands.

METHOD

Patients with ICPC-codes for gastric symptoms or ATC-code for acid inhibition in the period 2010-2020 were selected. Main outcomes were antimicrobial resistance of Hp, defined as the prescription of a second eradication treatment within 12 months, and clinical remission of gastric symptoms, defined as no usage of acid inhibition one year following eradication therapy.

RESULTS

We identified 138,455 patients with gastric symptoms and/or acid inhibition use (mean age 57 years [SD 18.2], 43% male). A total of 5,224 (4%) patients received a Hp eradication treatment. A second treatment was prescribed to 416 (8%) of those patients. From these, 380 patients received amoxicillin-clarithromycin, 16 amoxicillin-metronidazole and 11 clarithromycin-metronidazole as first regimen and were considered antimicrobial resistant. We observed a 0.8% increment per year of patients requiring a second eradication treatment (P=0.003, 95% CI 0.33-1.22). After successful eradication, 2,329/4,808 (48%) patients used acid inhibition compared to 355/416 (85%) patients following treatment failure (P<0.001).

CONCLUSION

Antimicrobial treatment is not successful in almost one-tenth of Hp infections in primary care after a first treatment containing clarithromycin and/or metronidazole. Although the treatment failure rate is not as high as reported in secondary care, the increasing trend is concerning and may require revision of the current guidelines.

Refractoriness to anti-Helicobacter pylori treatment attributed to phenotypic resistance patterns in patients with gastroduodenopathy in Guayaquil-Ecuador

BACKGROUND

Treatment of Helicobacter pylori gastric infection is complex and associated with increased rates of therapeutic failure. This research aimed to characterize the H. pylori infection status, strain resistance to antimicrobial agents, and the predominant lesion pattern in the gastroduodenal mucosa of patients with clinical suspicion of refractoriness to first- and second-line treatment who were diagnosed and treated in a health center in Guayaquil, Ecuador.

METHODS

A total of 374 patients with upper gastrointestinal symptoms and H. pylori infection were preselected and prescribed one of three triple therapy regimens for primary infection, as judged by the treating physician. Subsequently, 121 patients who returned to the follow-up visit with persistent symptoms after treatment were studied.

RESULTS

All patients had H. pylori infection. Histopathological examination diagnosed chronic active gastritis in 91.7% of cases; premalignant lesions were observed in 15.8%. The three triple therapy schemes applied showed suboptimal efficacy (between 47.6% and 77.2%), with the best performance corresponding to the scheme consisting of a proton pump inhibitor + amoxicillin + levofloxacin. Bacterial strains showed very high phenotypic resistance to all five antimicrobials tested: clarithromycin, 82.9%; metronidazole, 69.7%; amoxicillin and levofloxacin, almost 50%; tetracycline, 38.2%. Concurrent resistance to clarithromycin-amoxicillin was 43.4%, to tetracycline-metronidazole 30.3%, to amoxicillin-levofloxacin 27.6%, and to clarithromycin-metronidazole 59.2%.

CONCLUSIONS

In vitro testing revealed resistance to all five antibiotics, indicating that H. pylori exhibited resistance phenotypes to these antibiotics. Consequently, the effectiveness of triple treatments may be compromised, and further studies are needed to assess refractoriness in quadruple and concomitant therapies.

Heterogeneous osteoimmune profiles via single-cell transcriptomics in osteoporotic patients who fail bisphosphonate treatment

Postmenopausal osteoporosis arises from imbalanced osteoclast and osteoblast activity, and mounting evidence suggests a role for the osteoimmune system in bone homeostasis. Bisphosphonate (BP) is an antiresorptive agent, but its treatment failure rate can be as high as 40%. Here, we performed single-cell RNA sequencing on peripheral immune cells from carefully selected postmenopausal women: non-osteoporotic, osteoporosis improved after BP treatment, and BP-failed cases. We found an increase in myeloid cells in patients with osteoporosis (specifically, T cell receptor+ macrophages). Furthermore, lymphoid lineage cells varied significantly, notably elevated natural killer cells (NKs) in the BP-failed group. Moreover, we provide fruitful lists of biomarkers within the immune cells that exhibit condition-dependent differences. The existence of osteoporotic- and BP-failure-specific cellular information flows was revealed by cell-cell interaction analysis. These findings deepen our insight of the osteoporosis pathology enhancing comprehension of the role of immune heterogeneity in postmenopausal osteoporosis and BP treatment failure.

Treatment Failure in a UK Malaria Patient Harboring Genetically Variant Plasmodium falciparum From Uganda With Reduced In Vitro Susceptibility to Artemisinin and Lumefantrine

BACKGROUND

Recent cases of clinical failure in malaria patients in the United Kingdom (UK) treated with artemether-lumefantrine have implications for malaria chemotherapy worldwide.

METHODS

Parasites were isolated from an index case of confirmed Plasmodium falciparum treatment failure after standard treatment, and from comparable travel-acquired UK malaria cases. Drug susceptibility in vitro and genotypes at 6 resistance-associated loci were determined for all parasite isolates and compared with clinical outcomes for each parasite donor.

RESULTS

A traveler, who returned to the UK from Uganda in 2022 with Plasmodium falciparum malaria, twice failed treatment with full courses of artemether-lumefantrine. Parasites from the patient exhibited significantly reduced susceptibility to artemisinin (ring-stage survival, 17.3% [95% confidence interval {CI}, 13.6%-21.1%]; P < .0001) and lumefantrine (effective concentration preventing 50% of growth = 259.4 nM [95% CI, 130.6-388.2 nM]; P = .001). Parasite genotyping identified an allele of pfk13 encoding both the A675V variant in the Pfk13 propeller domain and a novel L145V nonpropeller variant. In vitro susceptibility testing of 6 other P. falciparum lines of Ugandan origin identified reduced susceptibility to artemisinin and lumefantrine in 1 additional line, also from a 2022 treatment failure case. These parasites did not harbor a pfk13 propeller domain variant but rather the novel nonpropeller variant T349I. Variant alleles of pfubp1, pfap2mu, and pfcoronin were also identified among the 7 parasite lines.

CONCLUSIONS

We confirm, in a documented case of artemether-lumefantrine treatment failure imported from Uganda, the presence of pfk13 mutations encoding L145V and A675V. Parasites with reduced susceptibility to both artemisinin and lumefantrine may be emerging in Uganda.

Detection of resistance to macrolides and fluoroquinolones in Mycoplasma genitalium by targeted next-generation sequencing

Mycoplasma genitalium is fastidious to culture, and its detection in human clinical specimens relies mainly on molecular methods. Phenotypic determination of antibiotic susceptibility for this bacterium is not a timely or feasible option for most clinical laboratories. This study sought to determine whether next-generation sequencing technologies can effectively be employed in determining genetic mutations associated with drug resistance in M. genitalium samples collected in Aptima Hologic tubes and possibly integrating them into viable workflows in public health laboratories. Following analysis by a custom-designed bioinformatics pipeline, at least one mutation/sample has been identified in 94/98 specimens in at least one of seven loci (macrolides: rrl, rplD, rplV; fluoroquinolones: parC, parE, gyrA, gyrB) described previously to be connected to antibiotic resistance. This method identified a total of 469 single nucleotide polymorphisms (SNPs) (452 mutations): 134 of 23S rRNA SNPs and 318 amino acid mutations: 114 substitutions and 204 synonymous; the turnaround time (sample to analyzed sequence) was typically 3 days. The assays and workflows described in this work demonstrated that the determination of a drug resistance profile for macrolides and fluoroquinolones of M. genitalium samples by using next-generation sequencing in clinical samples is a feasible approach that can be implemented in clinical laboratories, following thorough and extensive validation studies.IMPORTANCEThe mechanisms of drug resistance in Mycoplasma genitalium are complex and involve several genetic loci. The molecular methods for accurately characterizing resistance to fluoroquinolones and macrolides in this organism are often not available or approved for patient use and do not cover all genetic determinants. To this end, we propose a next-generation sequencing-based method with a turnaround time of 3 days that includes the investigation of all drug resistance loci of M. genitalium. Following adaptation, validation, and verification for routine clinical use, assays based on this method may yield molecular results that can be used to guide proper treatment regimens and for surveillance of drug resistance in the general population.

A Case of Cutaneous Leishmaniasis with Mucosal Involvement in the Northern United States

BACKGROUND

Cutaneous leishmaniasis (CL) is a vector-borne parasitic infection endemic to many sub-tropical regions worldwide. In the Americas, Leishmania braziliensis is responsible for most reported CL cases. Variable symptom presentation and susceptibility to secondary infection make diagnosing CL a difficult proposition for physicians who may not encounter cases frequently.

CASE REPORT

We present the case of a 50-year-old man with multiple progressive lesions, diagnosed initially as a bacterial infection, who presented to a North American emergency department after several unsuccessful trials of antibiotic therapy. Eventually, polymerase chain reaction testing of a wound biopsy sample confirmed the presence of L. braziliensis. After a complicated course, the patient's infection resolved after tailored antiparasitic therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the need to include travel history in the evaluation of atypical dermatologic infections.

Characteristics of Ischemic Stroke Despite Oral Anticoagulant Use For Atrial Fibrillation

Oral anticoagulation (OAC) prevents stroke in atrial fibrillation, yet a residual stroke risk remains. In this single-center retrospective analysis of acute ischemic stroke patients despite OAC, suboptimal OAC treatment is common (30%: inappropriate dosing (17%); patient non-adherence (13%)). Other causes of stroke included OAC interruption (14.5%), a competing stroke mechanism (11.0%), and undetermined breakthrough stroke in 44.5%. Overall, easily modifiable causes of ischemic stroke despite OAC are common. Accordingly, strategies to improve treatment compliance, including appropriate dosing along with guideline-based risk factor and periprocedural OAC management, should be emphasized to improve secondary stroke prevention in this patient population.

A retrospective cohort analysis of treatment outcomes of patients with tuberculosis who used substances in Tel Aviv, Israel

AIMS

To outline the demographic, clinical, laboratory characteristics, and treatment outcomes of tuberculosis (TB) patients who used substances.

METHODS

This retrospective cohort study compared 50 TB patients who used substances with a matched random sample of 100 TB patients who did not use substances between 2007 and 2017. Treatment failure was defined as a sputum smear or culture that tested positive after 5 months of treatment, loss to follow-up, unevaluated patients, or death.

RESULTS

TB patients who used substances were typically younger, experienced homelessness, smokers, and had fewer chronic diseases than those who did not use substances. They also were hospitalized for longer periods, their treatment durations were longer, had higher rates of multidrug resistant strains, increased rates of treatment failure, and higher mortality. Individuals whose treatment failed predominantly originated from the former Soviet Union, experienced homelessness, and had chronic diseases compared with those whose treatment was successful. In the multivariate analysis, homelessness [odds ratios (OR) = 6.7], chronic diseases (OR = 12.4), and substance use (OR = 4.0) were predictors of treatment failures.

CONCLUSIONS

TB patients who used substances were more likely to have treatment failure. Targeted interventions, including early diagnosis and enhanced support during treatment, are essential to achieve treatment success in this vulnerable population, in addition to TB-alcohol/drug collaborative activities.

Investigating rates and predictors of viral blips, low-level viraemia and virological failure in the Australian HIV observational database

OBJECTIVES

Australia has made significant progress towards achieving the UNAIDS's 95-95-95 cascade targets including HIV viral suppression. To investigate the burden of HIV viraemia, we assessed viral blips, low-level viraemia (LLV) and virologic failure (VF) in an Australian cohort.

METHODS

We studied the proportion of people with viral suppression, viral blips, LLV and VF in the Australian HIV observational database (AHOD) between 2010 and 2021. The association between blips or LLV, and VF was investigated using Cox regression, and predictors of viral blips and LLV were assessed using repeated-measured logistic regression.

RESULTS

Among 2544 AHOD participants who were in follow-up and on antiretroviral therapy (ART) from 1 January 2010 (88.7% male), 444 had experienced VF (incidence rate: 2.45 [95% CI: 2.23-2.69] per 100 person-years [PY]) during 18,125 PY of follow-up (a median of 7.6 years). The proportion of people with VF decreased over time, whereas rates of blips and LLV remained stable. Participants with blips (hazard ratio, 2.89; 95% CI: 2.31-3.61) and LLV (4.46; 95% CI: 3.38-5.89) were at increased risk of VF. Hepatitis B co-infection, longer documented treatment interruption duration, younger age and lower CD4 at ART initiation, and protease inhibitors-based initial regimen were associated with an increased risk of VF. Common predictors of blips and LLV such as higher HIV-1 RNA and lower CD4 at ART initiation, longer treatment interruption, more VL testing and types of care settings (hospitals vs. sexual health services) were identified.

CONCLUSIONS

Blips and LLV predict subsequent VF development. We identified important predictors of HIV viraemia including VF among individuals on INSTI-based regimens to help direct HIV management plans.

Early treatment with dipeptidyl-peptidase 4 inhibitors reduces glycaemic variability and delays insulin initiation in type 2 diabetes: A propensity score-matched cohort study

AIMS

To examine whether early treatment intensification using dipeptidyl-peptidase 4 inhibitors (DPP4i) delays insulin initiation in Chinese patients diagnosed with type 2 diabetes for less than 5 years.

MATERIALS AND METHODS

In a territory-wide prospective cohort study, patients with type 2 diabetes initiating DPP4i at diabetes duration <2 years (early intensification) and 3-5 years (late intensification) were matched using 1:1 propensity-score matching (n = 908 in each arm). We used Cox regression to compare the risk of insulin initiation between the two groups. We explored the interactive and mediation effects of glycated haemoglobin (HbA1c) variability score (HVS), defined as the percentage of HbA1c varying by ≥0.5% compared with preceding values.

RESULTS

Of 1816 patients (60.7% men, mean age 54.4 ± 11.9 years), 92.4% and 71.9% were treated with metformin and sulphonylureas respectively at DPP4i initiation. Early DPP4i intensification [hazard ratio (HR) 0.71, (95% CI 0.58-0.68)] and low HVS (<50%) (HR = 0.40, 0.33-0.50) were associated with delayed insulin initiation during a median 4.08 years of follow-up. Early intensification with low HVS had the lowest risk versus late intensification with high HVS (HR = 0.30, 0.22-0.40) (pinteraction  = 0.013). HVS mediated 19.5% of the total effect of early DPP4i intensification on delaying insulin initiation. The late and early intensification groups had similar HbA1c at month 0 (8.4 ± 1.3% vs. 8.4 ± 1.5%) and month 3 (7.6 ± 1.2% vs. 7.6 ± 1.3%) after DPP4i initiation. By month 12, HbA1c in the late intensification group deteriorated (7.9 ± 1.4%) but remained stable in the early intensification group (7.6 ± 1.4%, p = 0.001) with persistent between-group difference over 72 months (8.2 ± 1.7% vs. 7.7 ± 1.6%, p = 0.001).

CONCLUSIONS

In type 2 diabetes, early DPP4i intensification delayed insulin initiation, partially explained by reduced glycaemic variability.

Risk Factors and Outcomes for Isolation with Polymyxin B-Resistant Enterobacterales from 2018-2022: A Case-Control Study

Purpose

To analyze the risk factors and clinical outcomes of patients isolated with polymyxin B-resistant (PR) Enterobacterales from various clinical specimens to prevent and control the spread of these strains.

Methods

This retrospective case-control study included 72 PR Enterobacterales-positive cases and 144 polymyxin B-susceptible (PS) Enterobacterales controls from 2018 to 2022. Patients with PR Enterobacterales isolated in various clinical cultures were defined as cases. Patients with PS Enterobacterales cultures at similar anatomic sites during the same period were randomly selected as controls. Data were collected from clinical and laboratory test records. Bivariable logistic regression and Pearson's chi-square tests were used to assess risk factors.

Results

PR strains were predominantly Klebsiella pneumoniae (72.2%) and Salmonella enteritidis (8.3%). Of the patients, 66.04% were admitted to an intensive care unit (ICU). Risk factors for isolation with PR strains included chronic heart disease (P = 0.012; odds ratio [OR] 1.15; 95% confidence interval [CI] 1.03-1.28), immunosuppressant use (P = 0.016; OR 1.04 [1.0-1.07), drainage tube [head] (P = 0.006; OR 1.1 [1.0-1.1]), and polymyxin B exposure (P = 0.007; OR 1.03 [1.0-1.06]. With respect to outcomes, admission to an ICU (P = 0.003; OR 7.1 [1.9-25.4]), hypertension (P = 0.035; OR 1.4 [1.02-1.83]), and drainage tube [head] (P = 0.044; OR 1.1 [1.0-1.15]) were associated with treatment failure. Additionally, treatment failure was more frequent in patients (45.83%) than in controls (14.58%).

Conclusion

The major risk factors for isolation with PR strains were chronic heart disease, exposure to immunosuppressants, use of drainage tubes, and polymyxin B exposure. The isolation of PR strains in patients was a predictor of unfavorable outcomes. These findings provide a basis for monitoring the spread of PR Enterobacterales.

Clinical and radiological consequences of delayed therapy escalation in patients with relapsing-remitting multiple sclerosis

AIM OF THE STUDY

To evaluate the clinical and radiological consequences of delayed escalation of therapy in patients with relapsing-remitting multiple sclerosis (RRMS), in whom, despite finding platform therapy ineffective, high-efficacy drugs were introduced with a delay.

MATERIAL AND METHODS

We performed a single-centre, observational study evaluating patients with RRMS for ineffectiveness of disease-modifying therapies (DMTs). Depending on the time of therapy escalation to high-efficacy drugs, the patients were divided into an early escalation or a late escalation group, both of which were then observed for 48 months. All patients underwent a neurological examination every six months and a brain magnetic resonance imaging (MRI) every 12 months. The primary endpoint was a change in the Expanded Disability Status Scale (EDSS) score during the observation period. The secondary endpoint was the time to 6-month confirmed disability progression (6mCDP). In addition, we analysed the annualised relapse rate and the cumulative number of new Gd+ and T2 lesions on brain MRI.

RESULTS

165 patients were qualified for the analysis. On treatment initiation, mean age was 38 years (± 10.9), and mean EDSS was 1.41 ± 0.38. After 48 months, there was a statistically insignificant decrease in the EDSS score in the early escalation group (-0.17 ± 0.35; p > 0.05), while in the late escalation group there was an increase in the EDSS score. The highest increase was noted in the group in which the escalation was performed with a delay of more than two years (1.2 ± 0.63; p < 0.001), and moreover 80% of patients in this group met the 6mCDP criteria. The median time to 6mCDP was 4.6 years (LESC1) and 4.5 years (LESC2) in the late escalation groups. In the early escalation group, zero subjects met the 6mCDP criteria after 48 months of observation.

CONCLUSIONS

In everyday practice, the long-term outcomes in patients with RRMS and disease activity, despite DMT being used, are more favourable after early implementation of high-efficacy drugs. Delaying therapy escalation results in the accumulation of permanent disability in patients with RRMS.

Keeping It Simple: Developing a Prognostic Tool for Spinal Epidural Abscess

STUDY DESIGN

A retrospective study.

OBJECTIVE

To develop a prognostic score for mortality and treatment failure in Spinal epidural abscess (SEA), based on simplicity and multidimensional assessment principles.

METHODS

One-hundred-fifty patients were reviewed. Variables assessed included comorbidities, functional status, clinical presentation, Frankel classification, and biochemical and radiological parameters. The main outcomes were the 90-day mortality and treatment failure, corresponding to any intensification of the initial treatment plan. Variables were sorted out with a factorial analysis. Logistic regressions were performed, and the new score was derived from the coefficients. ROC curves with Area Under Curve, calibration plots, and cross-validation were performed.

RESULTS

Forty-three patients (29%) had treatment failure, and 15 died (10%) by 90 days. Factorization created 3 groups: Comorbidities (C), Severity (S), and Function (F). For 90-day mortality, Odds ratios were 1.20 (P = .0002), 1.15, (P = .03), 1.36, (P < 10-4) for C, S, F, respectively. The new score 'CSF' had 1 point per item, ranging from zero to 3. OR increased by 1.2/point for 90-day mortality (P < 10-4), AUC was .86. For failures OR increased by 1.15/point (P = .014), AUC was .58, and increased to .64 for patients who survived after 90 days, probably due to competing risks.

CONCLUSIONS

Comorbidities, Severity, and Function is a new simplistic tool, easy to use in daily practice; its performances were excellent for 90-day mortality, and acceptable for failures. Simple tools are more likely to be adopted into practice. External validation of this technique is desirable.

Middle Meningeal Artery Embolization versus Surgery in Patients with Chronic Subdural Hematoma-No More Fence Sitting?

BACKGROUND

Endovascular treatment of patients with chronic subdural hematoma using middle meningeal artery (MMA) embolization could become an alternative to surgical hematoma evacuation. The aim of the study was to compare methods and identify parameters to help determine the correct treatment modality.

METHODS

We retrospectively reviewed 142 cases conducted internally; 78 were treated surgically and 64 were treated using MMA embolization. We analyzed the treatment failure rate and complications, and using a binary logistic regression model, we identified treatment failure risk factors.

RESULTS

We found a comparable treatment failure rate of 23.1% for the surgery group and 21.9% for the MMA embolization group. However, in the MMA embolization group, 11 cases showed treatment failure due to early neurological worsening with a need for concomitant surgery. We also found a recurrence of hematoma in 15.4% of cases in the surgery group and 6.3% of cases in the MMA embolization group.

CONCLUSION

Both modalities have their advantages; however, correct identification is crucial for treatment success. According to our findings, hematomas with a maximal width of <18 mm, a midline shift of <5 mm, and no acute or subacute (hyperdense) hematoma could be treated with MMA embolization. Hematomas with a maximal width of >18 mm, a midline shift of >5 mm, and no membranous segmentation could have better outcomes after surgical treatment.

Criteria used to define tumor necrosis factor-alpha inhibitors failure in patients with moderate-to-severe psoriasis: a systematic literature review

BACKGROUND

Determining tumor necrosis factor-alpha inhibitors (anti-TNF-α) failure is still a challenge in the management of moderate-to-severe psoriasis. Thus, our comprehensive systematic literature review aimed to gather information on the criteria used to define anti-TNF-α failure. We also aimed to discover the main reasons for anti-TNF-α failure and define subsequently administered treatments.

MATERIALS AND METHODS

We conducted a systematic review following review and reporting guidelines (Cochrane and PRISMA). International (Medline/PubMed and Cochrane Library) and Spanish databases (MEDES, IBECS), and gray literature were consulted to identify publications issued until April 2021 in English or Spanish.

RESULTS

Our search yielded 58 publications. Of these, 37 (63.8%) described the criteria used to define anti-TNF-α primary or secondary failure. Criteria varied across studies, although around 60% considered Psoriasis Area and Severity Index (PASI)-50 criteria. Nineteen (32.8%) reported the reasons for treatment failure, including the lack or loss of efficacy and safety-related problems, mainly infections. Finally, 29 (50%) publications outlined the treatments administered after anti-TNF-α: 62.5% reported a switch to another anti-TNF-α and 37.5% to interleukin (IL)-inhibitors.

Our findings suggest a need to standardize the management of anti-TNF-α failure and reflect the incorporation of new targets, such as IL-inhibitors, in the treatment sequence.KEY MESSAGESIn the treatment of psoriasis, the primary and secondary anti-TNF-α failure criteria differ widely in the scientific literature.The strictest efficacy criteria for defining anti-TNF-α failure, or those recommended by guidelines such as PASI75, were underused both in clinical trials and observational studies.Most studies failed to consider patient-reported outcomes in assessing psoriasis treatment efficacy, which contrasts with recent recommendations on the inclusion of patient-reported HRQoL as a supporting criterion when considering clinical outcomes.

The Role of Therapeutic Drug Monitoring in Slow Response Extra-Pulmonary Tuberculosis Treatment: A Case Report

Tuberculosis is caused by an infectious bacterium and it has significant morbidity and mortality rates globally. It mostly affects the lungs, but it can also spread to other parts of the body, like the lymph nodes (tuberculous lymphadenitis). The most common way to treat it is with the RIPE regimen, which includes rifampin, isoniazid, pyrazinamide, and ethambutol. The drugs can be slowly or rapidly metabolized, resulting in either increased toxicity or subtherapeutic drug levels. In this paper, we discuss the case of a slow responder who was treated with increased rifampin and isoniazid doses and improved clinically and biochemically. It's the first case of a slow responder diagnosed with tuberculous lymphadenitis reported in the Gulf region.

Effect of different dialysis duration on the prognosis of peritoneal dialysis-associated peritonitis: a single-center, retrospective study

BACKGROUND

Peritoneal dialysis (PD)-associated peritonitis is a serious complication observed in peritoneal dialysis patients. Herein, we investigated the clinical characteristics and treatment outcomes of PD peritonitis in patients with different PD durations.

METHODS

All peritonitis episodes from January 2007 to December 2020 at Peking University People's hospital PD center were retrospectively analyzed and divided into the long-dialysis duration (≥60 months, LDD) and short-dialysis duration (<60 months, SDD) groups. Clinical characteristics and outcomes were compared between these groups. The risk factors for treatment failure were analyzed using a logistic regression model.

RESULTS

During 14 years, 156 patients had 267 peritonitis episodes. There were 83 (31.1%) peritonitis episodes in the LDD group and 184 (68.9%) in the SDD group. No statistical difference was noted in peritonitis causes and the composition of causative pathogens between the two groups. The hospitalization, treatment failure, and transfer-to-hemodialysis rates, and peritonitis-related mortality were significantly higher in the LDD group than in the SDD group (all p < .05). Logistic regression analysis revealed that PD duration was an independent risk factor for PD-associated hospitalization, treatment failure and peritonitis-related death (p < .05). The receiver operating characteristic curve analysis results showed that when the cutoff value of PD duration was 5.5 years, the sensitivity of predicting PD peritonitis treatment failure was 51.1%, specificity was 78.8%, and the area under the curve was 0.679 (95% confidence interval: 0.594-0.765, p < .001).

CONCLUSIONS

PD duration is an independent risk factor for poor prognosis in PD peritonitis. Careful and active attention should be paid to the prevention of peritonitis in PD patients with long PD duration.

Effectiveness and safety of once-daily tacrolimus formulations in de novo liver transplant recipients: The PRETHI study

Data comparing long-term effectiveness and safety of once-daily tacrolimus formulations in de novo liver transplantation are scarce. We compared the effectiveness, pharmacokinetic profile, and safety of LCPT (Envarsus) and PR-Tac (Advagraf) for up to 12 months post-transplant. Adult de novo liver transplant recipients who started IR-Tac (Prograf) and were converted to LCPT or PR-Tac 3-5 days post-transplant were included. Data from 163 patients were analyzed, 87 treated with LCPT and 76 with PR-Tac. The incidence of treatment failure was 30.5% in the LCPT group versus 23.0% in the PR-Tac group (p = .291). Biopsy-proven acute rejection (BPAR) was reported in 26.8% of patients in the LCPT group and 17.6% in the PR-Tac group (p = .166). Graft loss was experienced in one patient (1.2%) in the LCPT group and three patients (4.1%) in the PR-Tac group (p = .346). Death was registered in three patients (3.7%) in the LCPT group and three patients (4.1%) in the PR-Tac group (p > .999). Patients in the LCPT group showed 45.7% higher relative bioavailability (Cmin /total daily dose [TDD]; p < .01) with similar Cmin and 33.3% lower TDD versus PR-Tac (p < .01). The evolution of renal function, safety profile, and the incidence of post-transplant renal failure, dyslipidemia, obesity, hypertension, and diabetes mellitus were similar in patients treated with LCPT and PR-Tac. In de novo liver transplant patients, LCPT and PR-Tac showed comparable effectiveness with higher relative bioavailability, similar Cmin and lower TDD in the LCPT group. Renal function, safety, and post-transplant complications were comparable in LCPT and PR-Tac groups.

The impact of diabetes mellitus on the emergence of multi-drug resistant tuberculosis and treatment failure in TB-diabetes comorbid patients: a systematic review and meta-analysis

Background

The existence of Type 2 Diabetes Mellitus (DM) in tuberculosis (TB) patients is very dangerous for the health of patients. One of the major concerns is the emergence of MDR-TB in such patients. It is suspected that the development of MDR-TB further worsens the treatment outcomes of TB such as treatment failure and thus, causes disease progression.

Aim

To investigate the impact of DM on the Emergence of MDR-TB and Treatment Failure in TB-DM comorbid patients.

Methodology

The PubMed database was systematically searched until April 03, 2022 (date last searched). Thirty studies met the inclusion criteria and were included in this study after a proper selection process.

Results

Tuberculosis-Diabetes Mellitus patients were at higher risk to develop MDR-TB as compared to TB-non-DM patients (HR 0.81, 95% CI: 0.60-0.96, p < 0.001). Heterogeneity observed among included studies was moderate (I2 = 38%). No significant change was observed in the results after sub-group analysis by study design (HR 0.81, 95% CI: 0.61-0.96, p < 0.000). In the case of treatment failure, TB-DM patients were at higher risk to experience treatment failure rates as compared to TB-non-DM patients (HR 0.46, 95% CI: 0.27-0.67, p < 0.001).

Conclusion

The results showed that DM had a significant impact on the emergence of MDR-TB in TB-diabetes comorbid patients as compared to TB-non-DM patients. DM enhanced the risk of TB treatment failure rates in TB-diabetes patients as compared to TB-non-DM patients. Our study highlights the need for earlier screening of MDR-TB, thorough MDR-TB monitoring, and designing proper and effective treatment strategies to prevent disease progression.

Decreased Peripheral Blood Lymphocyte Count Predicts Poor Treatment Response in Peritoneal Dialysis-Associated Peritonitis

Purpose

Peripheral blood lymphocyte counts is a pivotal parameter in assessing the host's immune response during maladies and the equilibrium of the immune system which has been found to correlate with various diseases progression and prognosis. However, there was no study on patients with peritoneal dialysis-associated peritonitis (PDAP). We sought to investigate the prognostic value of baseline peripheral blood lymphocyte count in PDAP patients.

Patients and methods

This retrospective study analyzed data from 286 PDAP patients over nine years. Episodes were categorized according to the tertiles of peripheral blood lymphocyte counts (Very Low Lymphocyte Count (VLLC) Group, <0.72×106/L; Low Lymphocyte Count (LLC) Group, 0.72-1.11×106/L; Normal Lymphocyte Count (NLC) Group, ≥ 1.11×106/L). Demographic, laboratory, and infection-related variables were analyzed. Cox regression and generalized estimating equation (GEE) models were used to estimate the association between lymphocyte counts and PDAP treatment failure, which included PD catheter removal and death.

Results

After adjusting for other potential predictors, decreased lymphocyte counts exhibited an incremental relationship with the risk of treatment failure. The VLLC group indicated a 270% (95% CI, 1.168-6.247, P=0.020) and 273% (95% CI, 1.028-7.269, P=0.044) increased venture of treatment failure in Cox regression and GEE analyses, respectively, compared with the NLC group. As a continuous variable, the restricted cubic spline showed a linear negative correlation between lymphocyte counts and the treatment failure risk (P for overall = 0.026). The multivariate model C (combined lymphocyte count with baseline age, sex, dialysis age, Charlson Comorbidity index (CCI), etiology of kidney failure, hemoglobin, albumin, total bilirubin and infection type) showed an area under the curve of 0.824 (95% CI, 0.767-0.881, P=0.001) for the prediction of treatment failure.

Conclusion

Lower lymphocyte counts are linked to increased PDAP treatment failure risk. This highlights lymphocyte count's potential as a prognostic indicator for PDAP.

Two-Year Outcomes of Treatment-Experienced Adults After Programmatic Transitioning to Dolutegravir: Longitudinal Data From the VICONEL Human Immunodeficiency Virus Cohort in Lesotho

In the Viral Load Cohort North-East Lesotho (VICONEL) human immunodeficiency virus cohort, 14 242 adults had transitioned from efavirenz- or nevirapine-based antiretroviral therapy (ART) to dolutegravir-based ART by October 2021. Rates of viral suppression to <50 copies/mL were 84.8%, 93.9%, and 95.4% before, 12 months after, and 24 months after transition, respectively. Sex, age, pretransition viral load, and treatment backbone correlated with 24-month viremia.

Knee Injury and Osteoarthritis Outcome Score Interpretation Thresholds at 3 and 12 Months After Arthroscopic Meniscal Surgery. What Changes, and What Stays the Same?

OBJECTIVE: To evaluate the change in minimal important change (MIC), patient acceptable symptom state (PASS), and treatment failure (TF) thresholds for the Knee injury and Osteoarthritis Outcome Score (KOOS) from 3 to 12 months following arthroscopic meniscus surgery. DESIGN: Retrospective cohort study. METHODS: We included patients from the Knee Arthroscopy Cohort Southern Denmark who had meniscus surgery between 2013 and 2015. We calculated the interpretation threshold values for MIC, PASS, and TF using an anchor-based adjusted predictive modeling method. Thresholds at 3 and 12 months postoperatively were compared to evaluate changes over time. RESULTS: The proportions of people who reported a clinically relevant improvement, or their symptoms being acceptable, increased by 10% to 15% points from 3 to 12 months after surgery. MIC thresholds for the 5 KOOS subscales remained stable from 3 to 12 months with statistically nonsignificant differences (95% confidence intervals) ranging from -0.3 (-3.0, 2.6) to -2.4 (-6.1, 1.3). All PASS thresholds except for quality of life (QOL) decreased by -6.5 (-11.8, -1.5) to -3.7 (-7.1, -0.4) points, indicating that higher symptom levels were accepted at 12 months. In contrast, the proportion reporting their treatment to have failed remained stable over time (19% and 17%). For QOL, a 7.4 (2.0, 13.2) higher TF threshold at 12 months suggested that improved QOL was required to not consider that the treatment had failed. CONCLUSION: More patients reported being improved at 1 year compared to at 3 months following meniscus surgery. The KOOS MIC thresholds were stable over time, whereas time-specific PASS values should be applied after meniscus surgery. J Orthop Sports Phys Ther 2023;53(11):685-702. Epub 3 October 2023. doi:10.2519/jospt.2023.11993.

Dismal prognosis for cirrhotic patients with hepatitis C after initial failure of direct acting anti-virals, but salvage therapy may be life-saving

BACKGROUND

Effective direct-acting antiviral treatment against hepatitis C virus infection is available in many countries worldwide. Despite good treatment results, a proportion of patients does not respond to treatment. The aim of this study was to investigate the long-term prognosis and the outcome of salvage therapy, after an initial treatment failure, in a nation-wide real-life setting.

METHOD

Data from all adult patients registered in the national Swedish hepatitis C treatment register who did not achieve sustained virological response after initial antiviral treatment, was retrieved from 2014 through 2018.

RESULTS

In total, 288 patients with primary treatment failure were included, of whom 236 underwent a second treatment course as salvage therapy after a median delay of 353 (IQR: 215-650) days. Fifteen patients received a third treatment course as second salvage treatment after a further median delay of 193 (IQR: 160-378) days. One-hundred-eleven out of 124 (90%) non-cirrhotic and 62/79 (78%) cirrhotic patients achieved sustained virological response following the first salvage treatment. Sustained virological response was achieved by 108/112 (96%) patients who received a triple antiviral regimen. In total 69 patients were lost to follow-up or died waiting for salvage treatment. Baseline cirrhosis was associated with poor long-term survival.

CONCLUSION

Our study indicates that salvage therapy was effective in most patients with primary treatment failure, in particular when a triple direct acting antiviral regimen was given. To avoid the risk of death or complications, patients with primary treatment failure should be offered salvage therapy with a triple regimen, as soon as possible.

Reasons for antiretroviral switching in Colombia: A retrospective cohort study

INTRODUCTION

Long-term use of antiretroviral therapy (ART) for HIV infection might lead to the necessity of switching regimens. We aimed to analyze the reasons for the ART switch, the time-to-switch of ART, and its associated factors in a Colombian cohort.

METHODS

We conducted a retrospective cohort in 20 HIV clinics, including participants ≥18 years old with confirmed HIV infection who underwent an ART switch from January 2017 to December 2019 with at least 6 months of follow-up. A time-to-event analysis and an exploratory Cox model were performed.

RESULTS

796 participants switched ART during the study period. The leading cause of ART switch was drug intolerance (n = 449; 56.4%) with a median time-to-switch of 12.2 months. The longest median time-to-switch was due to regimen simplification (42.4 months). People ≥50 years old (HR = 0.6; 95% CI (0.5-0.7) and CDC stage 3 at diagnosis (HR = 0.8; 95% CI (0.6-0.9) had less hazard for switching ART over time.

CONCLUSIONS

In this Colombian cohort, drug intolerance was the main cause of the ART switch, and the time-to-switch is shorter than reports from other countries. In Colombia, it is crucial to apply current recommendations for ART initiation to choose regimens with a better tolerability profile.

Association of normalization of postoperative carbohydrate antigen 125 levels with treatment failure following uterine artery embolization for adenomyosis

OBJECTIVE

To investigate the association between carbohydrate antigen 125 (CA125) level and adenomyosis treatment failure (TF) after uterine artery embolization (UAE).

METHODS

We evaluated 224 patients with symptomatic adenomyosis who underwent UAE between January 2016 and December 2020. Improvements in dysmenorrhea and menorrhagia were assessed on the basis of symptom relief criteria. The factors associated with TF were investigated using a multivariate logistic regression model. Patients were analyzed for preoperative CA125 levels, postoperative CA125 levels, and the normalization of postoperative CA125 levels. Long-term symptom relief and quality of life after UAE were compared between the groups.

RESULTS

During the 24-month follow-up, 50 patients (22.3%) experienced TF. Compared to patients in the non-TF group, those in the TF group had significantly higher preoperative and postoperative CA125 levels (p < 0.05). Multivariate analysis revealed that failure to normalize postoperative CA125 levels was independently associated with an increased risk of TF (34.7% vs. 8.5%, p < 0.001; hazard ratio 3.953, 95% confidence interval 1.567-9.973, p = 0.004). After a 3-month follow-up period, patients who normalized their CA125 levels were more likely to achieve complete necrosis on magnetic resonance imaging than those who did not (82.1% vs. 56.8%, p < 0.001). Normalization of postoperative CA125 levels was significantly associated with fewer symptoms and better quality of life 12 months after UAE (p < 0.05).

CONCLUSIONS

Following UAE, normalization of postoperative CA125 levels, rather than absolute values, was the strongest predictive marker of TF.

Prediction of pulmonary tuberculosis treatment outcome in a sub-Saharan African context

Failure to treat many pathogens is a concern. Identifying a priori, patients with potential failure treatment outcome of a disease could allow measures to reduce the failure rate. The objectives of this study were to use the Scoring method to identify factors associated with the tuberculosis unsuccessful treatment outcome and to predict the treatment outcome. A total of 1,529 patients with pulmonary tuberculosis were randomly selected in the city of Douala, Cameroon, this sample was randomly split into two parts: one subsample of 1,200 patients (78%) used as the Development sample, and the remaining of 329 patients (22%) used as the Validation sample. Baseline characteristics associated with unsuccessful treatment outcomes were investigated using logistic regression. The optimal score was based on the Youden's index. HIV positive status, active smoker and non-belief in healing were the factors significantly associated with unsuccessful treatment outcomes (P#x003C;0.05). A model used to estimate the risk of unsuccessful treatment outcome was derived. The threshold probability which maximize the area under the ROC curve was 18%. Patients for whom the risk was greater than this threshold were classified as unsuccessful treatment outcome and the others as successful. HIV positive and active smoking status were associated with death; the non-belief in healing, youth and male gender associated with lost-to-follow-up, TB antecedent and not having TB contact associated with therapeutic treatment failure. To increase the tuberculosis treatment success rate, targeted follow-up could be taken during the treatment for TB patients with previous characteristics.

A nomogram prediction model for treatment failure in primary membranous nephropathy

BACKGROUND

Primary membranous nephropathy (PMN) has a heterogeneous natural course. Immunosuppressive therapy is recommended for PMN patients at moderate or high risk of renal function deterioration. Prediction models for the treatment failure of PMN have rarely been reported.

METHODS

This study retrospectively studied patients diagnosed as PMN by renal biopsy at Sichuan Provincial People's Hospital from January 2017 to December 2020. Information on clinical characteristics, laboratory test results, pathological examination, and treatment was collected. The outcome was treatment failure, defined as the lack of complete or partial remission at the end of 12 months. Simple logistic regression was used to identify candidate predictive variables. Forced-entry stepwise multivariable logistic regression was used to develop the prediction model, and performance was evaluated using C-statistic, calibration plot, and decision curve analysis. Internal validation was performed by bootstrapping.

RESULTS

In total, 310 patients were recruited for this study. 116 patients achieved the outcome. Forced-entry stepwise multivariable logistic regression indicated that PLA2Rab titer (OR = 1.002, 95% CI: 1.001-1.004, p = 0.003), inflammatory cells infiltration (OR = 2.753, 95% CI: 1.468-5.370, p = 0.002) and C3 deposition on immunofluorescence (OR = 0.217, 95% CI: 0.041-0.964, p = 0.049) were the three independent risk factors for treatment failure of PMN. The final prediction model had a C-statistic (95% CI) of 0.653 (0.590-0.717) and a net benefit of 23%-77%.

CONCLUSIONS

PLA2R antibody, renal interstitial inflammation infiltration, and C3 deposition on immunofluorescence were the three independent risk factors for treatment failure in PMN. Our prediction model might help identify patients at risk of treatment failure; however, the performance awaits improvement.

Advancing tuberculosis management: the role of predictive, preventive, and personalized medicine

Tuberculosis is a major global health issue, with approximately 10 million people falling ill and 1.4 million dying yearly. One of the most significant challenges to public health is the emergence of drug-resistant tuberculosis. For the last half-century, treating tuberculosis has adhered to a uniform management strategy in most patients. However, treatment ineffectiveness in some individuals with pulmonary tuberculosis presents a major challenge to the global tuberculosis control initiative. Unfavorable outcomes of tuberculosis treatment (including mortality, treatment failure, loss of follow-up, and unevaluated cases) may result in increased transmission of tuberculosis and the emergence of drug-resistant strains. Treatment failure may occur due to drug-resistant strains, non-adherence to medication, inadequate absorption of drugs, or low-quality healthcare. Identifying the underlying cause and adjusting the treatment accordingly to address treatment failure is important. This is where approaches such as artificial intelligence, genetic screening, and whole genome sequencing can play a critical role. In this review, we suggest a set of particular clinical applications of these approaches, which might have the potential to influence decisions regarding the clinical management of tuberculosis patients.

Time to Virological Failure and Its Predictor Among HIV-Positive Clients with the Differentiated Service Delivery Model of HIV at Debre Berhan Comprehensive Specialized Hospital, Amhara Regional State, Ethiopia, 2021: A Retrospective Cohort Study

Diversified antiretroviral therapy (ART) approach is needed in methods that were acceptable to communities and maintain good viral suppression outcomes to reach the UNAIDS targets to end the HIV/AIDS epidemic by 2030. Ethiopia is fully implementing differentiated service delivery (DSD) approaches, appointment spacing, and standard care. This study aimed to determine the time to HIV virological failure and its predictors among patients with a DSD model. An institution-based retrospective cohort study was conducted with data collection dates ranging from May 1, 2021, to May 30, 2021. All adult HIV-positive patients (n = 2,148) between January 2018 and January 2021 were a source population. Data were extracted using a standard checklist by trained data collectors and entered into EpiData, exported to SPSS version 20 for data management, and then exported to R Studio version 1.4 for analysis. Kaplan-Meier survival curves, the log-rank test, and Cox proportional hazard regression models were employed. The incidence of virological failure was 86 per 10,000 person-months. The independent predictors for the hazard of virological failure were being on standard care [adjusted hazard ratios (AHR) = 1.91; 95% confidence interval (CI) 1.07-3.40], primarily educated (AHR = 3.46; 95% CI 1.02-11.72), having no education (AHR = 3.45; 95% CI 1.01-11.85), and ambulatory status at baseline (AHR = 1.81; 95% CI 1.06-3.09). Patients who had a viral load with a detectable range from 50 to 999 at engagement (AHR = 2.65; 95% CI 1.33-5.27) and a 1-month increase in ART for HIV patients (AHR = 1.045; 95% CI 1.01-1.09). The incidence of virological failure was 86 per 10,000 person-months, whereas the incidences were 52 per 10,000 person-months and 71 per 10,000 person-months on appointment spacing model and standard care, respectively, with independent predictors: patient category, educational status, baseline functional status, viral load at engagement, and duration of ART.

Sustained weight loss with semaglutide once weekly in patients without type 2 diabetes and post-bariatric treatment failure

About 20%-25% of patients experience weight regain (WR) or insufficient weight loss (IWL) following bariatric surgery (BS). Therefore, we aimed to retrospectively assess the effectiveness of adjunct treatment with semaglutide in patients without type 2 diabetes (T2D) with post-bariatric treatment failure over a 12 months period. Post-bariatric patients without T2D with WR or IWL (n = 29) were included in the analysis. The primary endpoint was weight loss 12 months after initiation of adjunct treatment. Secondary endpoints included change in body mass index, HbA1c, lipid profile, high sensitive C-reactive protein and liver enzymes. Total weight loss during semaglutide treatment added up to 14.7% ± 8.9% (mean ± SD, p < .001) after 12 months. Categorical weight loss was >5% in 89.7% of patients, >10% in 62.1% of patients, >15% in 34.5% of patients, >20% in 24.1% of patients and > 25% in 17.2% of patients. Adjunct treatment with semaglutide resulted in sustained weight loss regardless of sex, WR or IWL and type of surgery. Among patients with prediabetes (n = 6), 12 months treatment led to normoglycemia in all patients (p < .05). Treatment options to manage post-bariatric treatment failure are scarce. Our results imply a clear benefit of adjunct treatment with semaglutide in post-bariatric patients over a 12 months follow-up period.

Clinical and Immunological Profiles of HIV/AIDS Patients With First-Line Antiretroviral Treatment Failure Attending a Tertiary Care Hospital

Objectives Highly active antiretroviral therapy (HAART) has decreased morbidity and mortality among HIV/AIDS-infected patients; however, many patients experience treatment failure. The present study aims to evaluate HIV-infected patients' clinical and immunological profiles with first-line antiretroviral treatment (ART) failure (immunological and clinical) at tertiary care hospitals in Northeast India and explore related treatment failure factors. Methods The hospital-based observational study was conducted among HIV-infected patients with first-line ART failure attending a tertiary care hospital from July 1, 2019, to June 30, 2020. The type of first-line ART failure was defined as a clinical, immunological, or virological failure as decided by the State AIDS Clinical Expert Panel (SACEP) meeting. Data were analyzed with Windows MS Excel (Microsoft Corporation, Redmond, Washington) and Statistical Package for the Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY). Results Among the 90 HIV-infected patients experiencing first-line ART treatment failure, the majority, 38 (42.2%), were in the age group of 30-40 years, 64 (71.1%) were males, and 70 (77.8%) were of average weight. Tuberculosis was the most typical opportunistic infection, affecting 11 (12.2%) patients. Most patients (38.9%) were initially presented at clinical stage 3. Maximum failures were experienced by patients with baseline CD4 ranging from 100-200 cells/mm3, with 38 (42.2%) patients, and by patients on efavirenz (64.5%) and tenofovir-based regimens (56.6%). Failures occurred more for 24-30 months and were common among patients with adherence below 90%. Conclusion Treatment failure was more common among young male patients and those with normal body mass index (BMI). Low baseline CD4 count and poor adherence were influential in the occurrence of treatment failure. First-line ART failure was higher in tenofovir- and efavirenz-based regimens.

Incidence of Rifampicin Resistance in Periprosthetic Joint Infection: A Single-Centre Cohort Study on 238 Patients

BACKGROUND

Rifampicin is a pillar in the treatment of periprosthetic joint infection (PJI). However, rifampicin resistance is an increasing threat to PJI treatment. This study explores the incidence of rifampicin-resistant bacteria over time in a Swedish tertiary referral centre and the association of rifampicin resistance with infection-free survival after PJI.

METHODS

The study included 238 staphylococcal PJIs treated between 2001 and 2020 for which susceptibility data for rifampicin were available. Data on causative bacteria, rifampicin resistance, treatment, and outcome were obtained. Kaplan-Meier survival analysis and Cox regression modelling estimated the infection-free cumulative survival and adjusted hazard ratios (HRs) for the risk of treatment failure.

RESULTS

Rifampicin-resistant causative bacteria were identified in 40 cases (17%). The proportion of rifampicin-resistant agents decreased from 24% in 2010-2015 to 12% in 2016-2020. The 2-year infection-free survival rates were 78.6% (95% CI, 66.4-93.1%) for the rifampicin-resistant group and 90.0% (95% CI, 85.8-94.4%) for the rifampicin-sensitive group. Patients with PJI caused by rifampicin-resistant bacteria had an increased risk of treatment failure (adjusted HR, 4.2; 95% CI, 1.7-10.3).

CONCLUSIONS

The incidence of PJI caused by rifampicin-resistant bacteria did not increase over the past 20 years. The risk of treatment failure in PJI caused by rifampicin-resistant bacteria is more than four times that caused by rifampicin-sensitive bacteria, highlighting the importance of limiting the development of rifampicin resistance.

Association between dialysis effluent leukocyte count after initial antibiotic treatment and outcomes of patients with peritoneal dialysis-associated peritonitis: a retrospective study

BACKGROUND

Among patients with peritoneal dialysis-associated peritonitis (PDAP), It has been regarded as an indicator of deterioration of clinical condition that peritoneal dialysis effluent leukocyte count (PDELC) cannot be restored to normal after initial antibiotic therapy. However, the precise relationship between PDELC on day 5 and the clinical outcomes of PDAP episodes remains uncertain.

AIMS

To explore the association between PDELC on day 5 and clinical outcomes of PDAP episodes.

METHODS

This retrospective study was based on the medical chart database of the Affiliated Hospital of Guangdong Medical University. Multivariable regressions were used to evaluate the association between PDELC on day 5 and 60-day mortality, half-year mortality, treatment failure, and the length of stay in hospital with adjustment for confounding factors.

RESULTS

A total of 549 PDAP episodes in 309 patients were enrolled. The total 60-day mortality, half-year mortality, and rate of treatment failure was 6.0%, 9.8%, and 14.2%, respectively. Compared with patients with normal PDELC, those with PDELC ≥2000 × 106/L on day 5 had significantly higher 60-day mortality (31.1% vs 2.7%), half-year mortality (35.6% vs 5.6%), and treatment failure (46.7% vs 5.7%). In multivariate adjusted regression, the ORs (95%CI) were 6.99 (2.33, 20.92; p = 0.001), 4.97(1.93, 12.77; p = 0.001), and 5.77 (2.07, 16.11; p = 0.001), respectively. Patients with PDELC were 100-2000 × 106/L on day 5 had a higher rate of treatment failure than those with normal PDELC (26.9% vs 5.7%) (OR = 3.03, 95%CI 1.42, 6.46; p = 0.004). After sensitivity analysis, the results remained robust.

CONCLUSIONS

Among patients with PDAP, increased PDELC on day 5 was associated with a greater risk of 60-day mortality, half-year mortality, and treatment failure.

Drug-Resistant Helicobacter pylori: Diagnosis and Evidence-Based Approach

Helicobacter pylori (H. pylori) is the most common chronic bacterial infection, affecting approximately half of the world's population. H. pylori is a Class I carcinogen according to the World Health Organization, and the International Agency for Research on Cancer (IARC) has linked it to 90% of stomach cancer cases worldwide. The overall pattern points to a yearly reduction in eradication rates of H. pylori with the likelihood of success further decreasing after each unsuccessful therapeutic effort. Antimicrobial resistance in Helicobacter pylori is a major public health concern and is a predominant cause attributed to eradication failure. As a result, determining H. pylori's antibiotic susceptibility prior to the administration of eradication regimens becomes increasingly critical. Detecting H. pylori and its antimicrobial resistance has traditionally been accomplished by time-consuming culture and phenotypic drug susceptibility testing. The resistance of H. pylori to different antibiotics is caused by various molecular mechanisms, and advances in sequencing technology have greatly facilitated the testing of antibiotic susceptibility to H. pylori. This review will summarize H. pylori antibiotic resistance patterns, mechanisms, and clinical implications. We will also review the pros and cons of current antibiotic susceptibility testing methods. Along with a comparison of tailored susceptibility-guided regimens and empirical therapy based on the latest evidence, an evidence-based approach to such situations will be explored.

Radiation therapy for low- and high-risk perineural invasion in head and neck cutaneous squamous cell carcinoma: Clinical outcomes and patterns of failure

BACKGROUND

Perineural invasion (PNI) in head and neck squamous cell carcinoma (HNSCC) portends poor prognosis. Extent of treatment of nerve pathways with varying degrees of PNI and patterns of failure following elective neural radiotherapy (RT) remain unclear.

METHODS

Retrospective review of HNSCC patients with high-risk (clinical/gross, large-nerve, extensive) or low-risk (microscopic/focal) PNI who underwent curative-intent treatment from 2010 to 2021.

RESULTS

Forty-four patients (mean follow-up 22 months; 59% high-risk, 41% low-risk PNI) were included. Recurrence following definitive treatment occurred in 31% high-risk and 17% low-risk PNI patients. Among high-risk patients, 69% underwent surgery with post-operative RT and 46% underwent elective neural RT. Local control (83% low-risk vs. 75% high-risk), disease-free, and overall survival did not differ between groups.

CONCLUSIONS

High local control rates were achieved in high-risk PNI patients treated with adjuvant or primary RT, including treatment of both involved and uninvolved, communicating cranial nerves, with few failures in electively treated regions.

Therapeutic Switching of Rafoxanide: a New Approach To Fighting Drug-Resistant Bacteria and Fungi

Control and management of life-threatening bacterial and fungal infections are a global health challenge. Despite advances in antimicrobial therapies, treatment failures for resistant bacterial and fungal infections continue to increase. We aimed to repurpose the anthelmintic drug rafoxanide for use with existing therapeutic drugs to increase the possibility of better managing infection and decrease treatment failures. For this purpose, we evaluated the antibacterial and antifungal potential of rafoxanide. Notably, 70% (70/100) of bacterial isolates showed multidrug resistance (MDR) patterns, with higher prevalence among human isolates (73.5% [50/68]) than animal ones (62.5% [20/32]). Moreover, 22 fungal isolates (88%) were MDR and were more prevalent among animal (88.9%) than human (87.5%) sources. We observed alarming MDR patterns among bacterial isolates, i.e., Klebsiella pneumoniae (75% [30/40; 8 animal and 22 human]) and Escherichia coli (66% [40/60; 12 animal and 28 human]), and fungal isolates, i.e., Candida albicans (86.7% [13/15; 4 animal and 9 human]) and Aspergillus fumigatus (90% [9/10; 4 animal and 5 human]), that were resistant to at least one agent in three or more different antimicrobial classes. Rafoxanide had antibacterial and antifungal activities, with minimal inhibitory concentration (MICs) ranging from 2 to 128 μg/mL. Rafoxanide at sub-MICs downregulated the mRNA expression of resistance genes, including E. coli and K. pneumoniae blaCTX-M-1, blaTEM-1, blaSHV, MOX, and DHA, C. albicans ERG11, and A. fumigatus cyp51A. We noted the improvement in the activity of β-lactam and antifungal drugs upon combination with rafoxanide. This was apparent in the reduction in the MICs of cefotaxime and fluconazole when these drugs were combined with sub-MIC levels of rafoxanide. There was obvious synergism between rafoxanide and cefotaxime against all E. coli and K. pneumoniae isolates (fractional inhibitory concentration index [FICI] values ≤ 0.5). Accordingly, there was a shift in the patterns of resistance of 16.7% of E. coli and 22.5% of K. pneumoniae isolates to cefotaxime and those of 63.2% of C. albicans and A. fumigatus isolates to fluconazole when the isolates were treated with sub-MICs of rafoxanide. These results were confirmed by in silico and mouse protection assays. Based on the in silico study, one possible explanation for how rafoxanide reduced bacterial resistance is through its inhibitory effects on bacterial and fungal histidine kinase enzymes. In short, rafoxanide exhibited promising results in overcoming bacterial and fungal drug resistance. IMPORTANCE The drug repurposing strategy is an alternative approach to reducing drug development timelines with low cost, especially during outbreaks of disease caused by drug-resistant pathogens. Rafoxanide can disrupt the abilities of bacterial and fungal cells to adapt to stress conditions. The coadministration of antibiotics with rafoxanide can prevent the failure of treatment of both resistant bacteria and fungi, as the resistant pathogens could be made sensitive upon treatment with rafoxanide. From our findings, we anticipate that pharmaceutical companies will be able to utilize new combinations against resistant pathogens.

Clinical Efficacy of Fidaxomicin and Oral Metronidazole for Treating Clostridioides difficile Infection and the Associated Recurrence Rate: A Retrospective Cohort Study

Clostridioides difficile infection (CDI) has significant implications for healthcare economics. Although clinical trials have compared fidaxomicin (FDX) and vancomycin, comparisons of FDX and oral metronidazole (MNZ) are limited. Therefore, we compared the therapeutic effects of FDX and oral MNZ. Patients diagnosed with CDI between January 2015 and March 2023 were enrolled. Those treated with oral MNZ or FDX were selected and retrospectively analyzed. The primary outcome was the global cure rate. Secondary outcomes included factors contributing to the CDI global cure rate; the rate of medication change owing to initial treatment failure; and incidence rates of clinical cure, recurrence, and all-cause mortality within 30 days. Of the 264 enrolled patients, 75 and 30 received initial oral MNZ and FDX treatments, respectively. The corresponding CDI global cure rates were 53.3% and 70% (p = 0.12). In multivariate analysis, FDX was not associated with the global cure rate. In the MNZ group, 18.7% of the patients had to change medications owing to initial treatment failure. The FDX group had a higher clinical cure rate and lower recurrence rate than the MNZ group, although not significant. However, caution is necessary owing to necessary treatment changes due to MNZ failure.

Potential Implication of Azole Persistence in the Treatment Failure of Two Haematological Patients Infected with Aspergillus fumigatus

Invasive aspergillosis (IA) is a major cause of morbidity and mortality in patients receiving allogeneic haematopoieticcell transplantation. The deep immunosuppression and a variety of potential additional complications developed in these patients result in IA reaching mortality rates of around 50-60%. This mortality is even higher when the patients are infected with azole-resistant isolates, demonstrating that, despite the complexity of management, adequate azole treatment can have a beneficial effect. It is therefore paramount to understand the reasons why antifungal treatment of IA infections caused by azole-susceptible isolates is often unsuccessful. In this respect, there are already various factors known to be important for treatment efficacy, for instance the drug concentrations achieved in the blood, which are thus often monitored. We hypothesize that antifungal persistence may be another important factor to consider. In this study we present two case reports of haematological patients who developed proven IA and suffered treatment failure, despite having been infected with susceptible isolates, receiving correct antifungal treatment and reaching therapeutic levels of the azole. Microbiological analysis of the recovered infective isolates showed that the patients were infected with multiple strains, several of which were persisters to voriconazole and/or isavuconazole. Therefore, we propose that azole persistence may have contributed to therapeutic failure in these patients and that this phenomenon should be considered in future studies.

Highly active antiretroviral therapy discontinuation time is associated with therapeutic failure among human immunodeficiency virus (HIV)-infected immigrant adults: A cohort study from a Peruvian referral hospital during the Venezuelan exodus

OBJECTIVE

To evaluate the association between Highly Active Antiretroviral Therapy (HAART) discontinuation time and therapeutic failure (TF) in Venezuelan immigrants with HIV that restart HAART.

METHODS

We carried out a retrospective cohort study in a large hospital in Peru. We included Venezuelan immigrants who restarted HAART and were followed over at least 6 months. The primary outcome was TF. Secondary outcomes were immunologic (IF), virologic (VF) and clinical (CF) failures. The exposure variable was HAART discontinuation, categorised as no discontinuation, less than 6 months, and 6 months or more. We applied generalised linear models Poisson family with robust standard errors to calculate crude (cRR) and adjusted (aRR) relative risks by statistical and epidemiological criteria.

RESULTS

We included 294 patients, 97.2% were males, and the median age was 32 years. Out of all the patients, 32.7% discontinued HAART for less than 6 months, 15.0% discontinued for more than 6 months and the remaining 52.3% did not discontinue. The cumulative incidence of TF was 27.9%, 24.5% in VF, 6.0% in IF and 6.0% in CF. Compared with non-discontinued HAART patients, the discontinuation for less than 6 months (aRR = 1.98 [95% CI: 1.27-3.09]) and from 6 months to more (aRR = 3.17 [95% CI: 2.02-4.95]) increased the risk of TF. Likewise, treatment discontinuation of up to 6 months (aRR = 2.32 [95% CI: 1.40-3.84]) and from 6 months to more (aRR = 3.93 [95% CI: 2.39-6.45]) increased the risk of VF.

CONCLUSIONS

HAART discontinuation increases the probability of TF and VF in Venezuelan immigrants.

LONEPINELLA SP. ISOLATED FROM WOUND INFECTIONS OF KOALAS

We describe two cases of wound infections of koalas (Phascolarctos cinereus), one wild and one captive, in which Lonepinella-like organisms were involved. The wild adult koala was captured with bite wound injuries, as part of a koala population management program in Queensland, Australia. In both cases, there was evidence of physical trauma causing the initial wound. The captive koala suffered injury from the cage wire, and the wild koala had injuries suggestive of intermale fighting. Gram-negative bacteria isolated from both cases proved to be challenging to identify using routine diagnostic tests. The wound in the captive koala yielded a pure culture of an organism shown by whole genome sequence (WGS) analysis to be a member of the genus Lonepinella, but not a member of the only formally described species, L. koalarum. The wound of the wild koala yielded a mixed culture of Citrobacter koseri, Enterobacter cloacae and an organism shown by WGS analysis to be Lonepinella, but again not Lonepinella koalarum. Both cases were difficult to treat; the captive koala eventually had to have the phalanges amputated, and the wild koala required removal of the affected claw. The two Lonepinella isolates from these cases have a close relationship to an isolate from a human wound caused by a koala bite and may represent a novel species within the genus Lonepinella. Wound infections in koalas linked to Lonepinella have not been reported previously. Wildlife veterinarians need to be aware of the potential presence of Lonepinella-like organisms when dealing with wound infections in koalas, and the inability of commercial kits and systems to correctly identify the isolates.

Novel signatures of prostate cancer progression and therapeutic resistance

INTRODUCTION

The extensive heterogeneity of prostate cancer (PCa) and multilayered complexity of progression to castration-resistant prostate cancer (CRPC) have contributed to the challenges of accurately monitoring advanced disease. Profiling of the tumor microenvironment with large-scale transcriptomic studies have identified gene signatures that predict biochemical recurrence, lymph node invasion, metastases, and development of therapeutic resistance through critical determinants driving CRPC.

AREAS COVERED

This review encompasses understanding of the role of different molecular determinants of PCa progression to lethal disease including the phenotypic dynamic of cell plasticity, EMT-MET interconversion, and signaling-pathways driving PCa cells to advance and metastasize. The value of liquid biopsies encompassing circulating tumor cells and extracellular vesicles to detect disease progression and emergence of therapeutic resistance in patients progressing to lethal disease is discussed. Relevant literature was added from PubMed portal.

EXPERT OPINION

Despite progress in the tumor-targeted therapeutics and biomarker discovery, distant metastasis and therapeutic resistance remain the major cause of mortality in patients with advanced CRPC. No single signature can encompass the tremendous phenotypic and genomic heterogeneity of PCa, but rather multi-threaded omics-derived and phenotypic markers tailored and validated into a multimodal signature.