Case Report with Systematic Literature Review on Vascular Complications of BCG Intravesical Therapy for Bladder Cancer.

(1) Background: Intravesical instillation of therapeutic Bacillus Calmette-Guerin (BCG) is the standard of treatment for non-muscular invasive bladder cancer. Although the exact immunomodulatory effects of BCG therapy in non-muscular invasive bladder cancer (NMIBC) are still unclear, it has been considered a safe and effective treatment with the largest to-date report of complications citing minimal side effects, none of which included arterial involvement; (2) Methods: A systematic literature review was performed using PubMed, Cochrane, Medline, and Google Scholar from database inception to March 2021. Only eligible studies reporting aneurysm formation in adult patients with a history of BCG immunotherapy and no previous vascular pathology were included; (3) Results: A systematic literature review was conducted, highlighting 17 reports suggestive of BCG-induced mycotic aneurysm development. We added a case of a 78-year-old male, 30 months after last BCG-instillation, with a mycotic abdominal aneurysm yielding Mycobacterium tuberculosis with pyrazinamide resistance culture.; (4) Conclusions: Concluding results suggest a higher incidence of vascular complications from BCG intravesical therapy in the treatment of non-muscular invasive bladder cancer than previously reported. Recommendations are made to emphasize further research of this immunotherapy complication to facilitate the creation of guidelines for diagnosis and management of these patients.

West Nile virus in a patient with Good's syndrome.

We describe the association between thymoma and hypogammaglobulinemia (Good's Syndrome) and a fulminant, seronegative West Nile Virus neuroinvasive infection confirmed by nucleic acid amplification. Diagnostic difficulties are emphasized and historical minutiae are highlighted.

The nerve of legal entrapment.

Chordomas are a rare type of bone tumor that arises from the embryological remnant of the notochord. They originate at any point along the axial spine with the sacrum and the skull based region being the most commonly affected sites. Chordomas are slowly growing, indolent tumors, presenting insidiously, but also carry a high recurrence rate with a tendency to invade contiguous structure making their treatment challenging. The current standard of care for localized chordoma is aggressive cytoreductive surgery followed by high dose adjuvant radiotherapy. We present a unique case of a 72-year-old lawyer with a skull base chordoma invading into the hypoglossal canal and causing isolated hypoglossal nerve paralysis.

Multiple coronary aneurysms in a young adult with acquired immunodeficiency syndrome.

HIV infection can cause multiple deleterious effects on the cardiovascular system. Emerging evidence has supported a direct association between HIV infection and accelerated atherosclerosis. The mechanism for atherosclerosis in HIV-positive patients is multifactorial, an interplay between conventional risk factors, HIV itself and highly active antiretroviral therapy. The case described is a 29-year-old man with HIV, non-adherent to antiretroviral therapy and with few cardiovascular risk factors, who presented with chest pain and non-ST elevation myocardial infarction. Cardiac catheterization revealed multiple coronary artery aneurysms in the left main coronary artery and the right coronary artery. Aneurysmal formation may develop from vasculitis, HIV itself, accelerated atherosclerosis, congenital formation or medications (e.g. protease inhibitors). The researchers provide a review of coronary artery disease, aneurysmal formation and vasculitic processes in the context of HIV. As this clinical entity becomes more apparent, alternative therapeutic options may need to be explored.

The immune response to surgery and trauma: Implications for treatment.

BACKGROUND: Infection after surgery and trauma is a major cause of increased morbidity, mortality, and cost. Alterations of the hosts immune system following these insults is believed to be responsible for the increased risk of infection. The hosts' immune response to tissue injury is widely believed to follow a bimodal response, with the systemic inflammatory response syndrome (SIRS) followed by the compensated anti-inflammatory response syndrome (CARS). Recent data, however, suggests that his paradigm may not be correct. METHODS: We reviewed the literature to describe the immunological changes following surgery and trauma and possible therapeutic interventions to limit this process. RESULTS: Physical injury related to trauma and surgery increase the expression of T-helper 2 (Th2) lymphocytes which cause impaired cell mediated immunity (CMI). Activation of the hypothalamic-pituitary-adrenal (HPA) axis and sympathoadrenal system (SAS) with the release of cortisol and catecholamines appear to be responsible for altering the Th1/Th2 balance. Decreased expression and signalling of interleukin-12 (IL-12) and increased expression of T regulatory cells (Tregs) appear to play a central role in mediating this immune depression. Furthermore, Th2 cytokines increase the expression of arginase-1 (ARG1) in myeloid-derived suppressor cells (MDSC's) causing an arginine deficient state, which further impairs lymphocyte function. Immunomodulating diets (IMDs) containing supplemental arginine and omega-3 fatty acids have been demonstrated to restore the Th1/Th2 balance after surgical trauma and to reduce the risk of infectious complications. ß-adrenergic receptor blockage reverses the Th-1 to Th2 shift and preliminary data suggests that such therapy may be beneficial. CONCLUSION: Tissue injury following surgery and trauma results in depressed CMI leading to an increased risk of infections. The peri-operative use of IMDs appear to reverse this immunosuppression and decrease the risk of postoperative complications. While ß-adrenoreceptor blockage may be beneficial in these patients, particularly when combined with a IMD, additional research is required.

The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.

BACKGROUND: Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed. OBJECTIVE: A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement. DATA SOURCES: MEDLINE, Embase, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles, and an Internet search (Google). STUDY SELECTION: Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement. DATA EXTRACTION: Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis. Studies were subgrouped according to study design (cohort and randomized controlled trials). Meta-analytic techniques were used to summarize the data. DATA SYNTHESIS: Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p=.01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies. CONCLUSIONS: Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.

Chronic acetaminophen ingestion resulting in severe anion gap metabolic acidosis secondary to 5-oxoproline accumulation: an under diagnosed phenomenon.

Anion gap metabolic acidosis is commonly caused by lactic acidosis, ketoacidosis, and ingestion of methanol, salicylates, ethylene glycol or accumulation of organic/inorganic acids. However, rare causes of metabolic acidosis from enzyme defects, such as disturbances in the γ-glutamyl cycle, are being reported in higher frequencies in the adult population. Such disturbances cause an accumulation of 5-oxoproline and ultimately an anion gap metabolic acidosis. These disturbances are often associated with acetaminophen in the setting of certain risk factors such as sepsis, malnutrition, liver disease, female gender, pregnancy or renal failure.

Do dietary supplements have beneficial health effects in industrialized nations: what is the evidence?

BACKGROUND: Dietary supplements are regularly used by at least half of the American population, yet the health benefits of these agents are unclear. OBJECTIVE: A systematic review to determine the benefits and risks of dietary supplements in Westernized societies. DATA SOURCES: MEDLINE, Embase, Cochrane Register of Controlled Trials and citation review of relevant articles. STUDY SELECTION: Randomized, placebo-controlled clinical trials in non-pregnant Westernized adults that evaluated clinical outcomes of nutritional supplements. DATA EXTRACTION: Data were abstracted on study design, study size, study setting, patient population, dietary intervention and clinical outcomes. The outcome of each study was classified as non-beneficial, beneficial or harmful according to whether the end-point(s) of interest reached statistical significance. DATA SYNTHESIS: Sixty-three studies met the criteria for our systematic review. No benefit was recorded in 45 studies, with 10 of these showing a trend towards harm and with two showing a trend towards benefit. Four studies reported harm with increased cancer deaths (n=2) and increased fractures (n=2). Two studies reported both a harmful as well as a beneficial outcome. A beneficial outcome was reported in 12 studies; 6 which studied vitamin D and three which investigated omega-3 fatty acids. While a benefit was reported in one study each which investigated Vitamin E, folic acid and Ginkgo biloba this benefit was not confirmed by larger and more adequately powered studies. CONCLUSIONS: With the possible exceptions of Vitamin D and omega-3 fatty acids there is no data to support the widespread use of dietary supplements in Westernized populations; indeed, many of these supplements may be harmful.

Narrative review: the management of acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is the most common reason for hospitalization in Western nations. The prognosis of patients admitted to hospital with ADHF is poor, with up to 64% being readmitted within the first 90 days after discharge and with a 1-year mortality approximating 20%. Epidemiological studies suggest that the majority of patients hospitalized with ADHF receive treatment that is inadequate and which is not based on scientific evidence. Furthermore, emerging data suggest that the "conventional" therapeutic interventions for ADHF including morphine, high-dose diuretics, and inotropic agents may be harmful. The goal of this review is to provide evidence-based recommendations for the diagnosis and management of ADHF.

Blood B-type natriuretic peptide and dialysis: present assessment and future analyses.

Brain natriuretic peptide (BNP) is elevated in hemodialysis (HD) patients and predicts increased mortality. Intra- and interdialytic changes in BNP have not been fully described. End-stage renal disease (ESRD) patients were prospectively recruited at three dialysis centers. At five visits, over a 6-week period, pre- and postdialysis BNP levels were measured. Pre- and postdialysis weights, blood pressure, fluid removed/given and demographic/medical information were recorded. Mean pre- and post-HD BNP (log-transformed) was not significantly different and did not correlate with fluid removed. Both pre- and post-HD BNP significantly decreased across the dialysis week (Pre-HD: intercept = 2.69, slope = -0.097, t = -6.7, P < 0.001) and across the five sessions (slope = -0.046, t = -2.47, P = 0.01). Interdialytic BNP changes are not related to fluid removed. Chronic volume overload and increased left ventricular wall tension likely account for the BNP decrease across dialysis weeks and may be related to higher death rates among HD patients at the beginning of the week.

The agony and the ecstasy.

The authors, who are from the Vessel Sanitation Program of the Centers for Disease Control and Prevention (CDC), summarize the recent outbreaks of acute gastroenteritis (AGE), which occurred on five different cruise ships. Attack rates among passengers ranged from 4% to 13% and among crew members from 0.2% to 3.3%. Subsequent epidemiological investigations by the CDC suggested that the incidence was higher, approaching 19-41% of passengers. Overall there were 21 outbreaks of AGE on 17 cruise ships, of which nine were documented to be due to norovirus, three due to bacterial agents, and nine of unknown cause. In general, subsequent outbreaks on each cruise ship were of the identical strain of norovirus by reverse transcriptase polymerase reaction, which suggests an embedded source. The authors conclude that in addition to emphasizing basic food and water sanitation measures, control efforts should include thorough and prompt disinfection of ships during cruises and isolation of ill crew-members and passengers for 72 hours.

Current Insights in Whipple's Disease.

Therapy for Whipple's disease should be continued for a minimum of 1 year, and the regimen should include an agent or agents that achieve acceptable concentrations in the central nervous system, given the likelihood of recurrence at this site. Clinical follow-up of proven cases of Whipple's disease should be conducted for a minimum of 10 years after discontinuation of therapy, given the potential for late relapses. Polymerase chain reaction analysis is preferred rather than endoscopy when evaluating for disease recurrence.

Diabetes and macrovascular disease.

Cardiovascular disease (CVD) is the major cause of morbidity and mortality in patients with diabetes. Macrovascular events, including stroke, myocardial infarction (MI), and peripheral arterial disease (PAD), occur earlier than in nondiabetics and the underlying pathologies are often more diffuse and severe. Diabetic arteriopathy, which encompasses endothelial dysfunction, hypercoagulability, changes in blood flow, and platelet abnormalities, contributes to the early evolution of these events. Tight glucose and blood pressure control improves the vascular status of these patients by varying degrees. Antiplatelet agents have also been shown to be effective in the secondary prevention of cardiovascular events. In the ideal world, every risk factor would be addressed and each diabetic would have excellent glycemic control, a low normal blood pressure, a low LDL, and be prescribed an ACE inhibitor, together with aspirin and clopidogrel. If this is done, this emerging epidemic of macrovascular disease will be contained.

Predicción de la trombosis venosa profunda por el dímero-D / Prediction of deep venous thrombosis from D dimer

Las determinaciones del dímero-D se utilizarán cada vez con mayor frecuencia para descartar las trombosis venosas y la innecesaria utilización de la angiografía pulmonar. La generación de pruebas para la determinación de los niveles de dímero-D debería aportar ensayos confiables y reproducibles en la práctica clínica, ya que los ensayos cualitativos disponibles hasta el momento, basados en el método de aglutinación con látex, son poco confiables para su uso clínico

Predicción de la trombosis venosa profunda por el dímero-D / Prediction of deep venous thrombosis from D dimer

Las determinaciones del dímero-D se utilizarán cada vez con mayor frecuencia para descartar las trombosis venosas y la innecesaria utilización de la angiografía pulmonar. La generación de pruebas para la determinación de los niveles de dímero-D debería aportar ensayos confiables y reproducibles en la práctica clínica, ya que los ensayos cualitativos disponibles hasta el momento, basados en el método de aglutinación con látex, son poco confiables para su uso clínico