Multidisciplinary approach to diagnosis and management of fever of unknown origin: A case report.

INTRODUCTION: Fever of unknown origin (FUO) poses a diagnostic challenge, often requiring a systematic evaluation to uncover its elusive cause. This case study delves into the presentation of a 42-year-old Chinese male with persistent fever, muscle pain, and a perplexing rash. PATIENT CONCERNS: The patient's symptoms included a prolonged fever, chills, muscle pain, and throat discomfort, with a history of pulmonary tuberculosis. Initial diagnoses of upper respiratory infection and unspecified infection were followed by antibiotic treatments, yet the fever persisted, accompanied by an exacerbating rash. DIAGNOSIS: Extensive diagnostic investigations, including laboratory tests, imaging studies, and skin dermoscopy, provided valuable insights. The patient exhibited elevated inflammatory markers, hepatosplenomegaly, lymphadenopathy, and lung nodules. Differential diagnoses included adult-onset Still disease and drug-induced hypersensitivity syndrome. INTERVENTIONS: The patient received a series of antibiotic treatments, which initially had limited success. Upon considering an autoimmune etiology, corticosteroids were introduced, followed by cyclosporine. The patient exhibited a positive response to this immunosuppressive therapy. OUTCOMES: Treatment adjustments were made, and the patient responded positively to a combination of corticosteroids and cyclosporine. His fever subsided, and laboratory markers normalized. One month after discharge, the patient showed continued improvement. CONCLUSION: FUO cases often demand a multidisciplinary approach, considering rare and uncommon diseases. This case underscores the importance of thorough evaluation, collaboration between specialties, and vigilant monitoring of treatment responses. The patient's unique presentation emphasizes the need to consider drug-induced reactions, even when symptoms deviate from typical disease patterns, highlighting the complexities in diagnosing and managing FUO.

Advances in gut microbiome in metabonomics perspective: based on bibliometrics methods and visualization analysis.

Background and aims: Gastrointestinal microbial metabolomics is closely related to the state of the organism and has significant interaction with the pathogenesis of many diseases. Based on the publications in Web of Science Core Collection(WoSCC) from 2004 to 2022, this study conducted a bibliometric analysis of this field, aiming to understand its development trend and frontier, and provide basic information and potential points for in-depth exploration of this field. Methods: All articles on gastrointestinal flora and metabolism published from 2004 to 2022 were collected and identified in WoCSS. CiteSpace v.6.1 and VOSviewer v.1.6.15.0 were used to calculate bibliometric indicators, including number of publications and citations, study categories, countries/institutions, authors/co-cited authors, journals/co-cited journals, co-cited references, and keywords. A map was drawn to visualize the data based on the analysis results for a more intuitive view. Results: There were 3811 articles in WoSCC that met our criteria. Analysis results show that the number of publications and citations in this field are increasing year by year. China is the country with the highest number of publications and USA owns the highest total link strength and citations. Chinese Acad Sci rank first for the number of institutional publications and total link strength. Journal of Proteome Research has the most publications. Nicholson, Jeremy K. is one of the most important scholars in this field. The most cited reference is "Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease". Burst detection indicates that Urine, spectroscopy, metabonomic and gut microflora are long-standing hot topics in this field, while autism spectrum disorder and omics are likely to be at the forefront of research. The study of related metabolic small molecules and the application of gastrointestinal microbiome metabolomics in various diseases are currently emerging research directions and frontier in this field. Conclusion: This study is the first to make a bibliometric analysis of the studies related to gastrointestinal microbial metabolomics and reveal the development trends and current research hotspots in this field. This can contribute to the development of the field by providing relevant scholars with valuable and effective information about the current state of the field.

Upregulation of TMEM40 is associated with the malignant behavior and promotes tumor progression in cervical cancer.

OBJECTIVE: Recent studies indicated that transmembrane protein 40 (TMEM40) is associated with several types of cancers but is not clear in cervical cancer (CC). The study aimed to examine the role of TMEM40 in CC and related mechanisms. METHODS: The expression of TMEM40 in CC tissues and cell lines was studied with western blot and real-time quantitative RT-PCR. The effect of TMEM40 on proliferation was evaluated by CCK-8, EdU and colony formation assay. The migration, invasion, cell cycle and apoptosis of CC cells were studied with wound healing, transwell assays and flow cytometry. Tumor growth was evaluated in vivo using a xenogenous subcutaneously implant model. RESULTS: The results revealed that the TMEM40 elevation in CC tissues and cell lines was closely correlated with tumor size and lymph node metastasis in clinical patients. Upregulation of TMEM40 with OE-TMEM40 vector promoted the invasion, migration and proliferation, inhibited the apoptosis and led to distinct S cell cycle arrest in CC cell lines. Silencing TMEM40 with shRNA inhibited the invasion, migration and proliferation, promoted apoptosis and led to a G0/G1 cell cycle arrest in CC cell lines. Silence of TMEM40 downregulated the expression of c-MYC, Cyclin D1, matrix metalloproteinase-1 (MMP-1) and matrix metalloproteinase-9 (MMP-9), but in contrast, activated p53 and several apoptosis related proteins such as p53, Caspase-3, Caspase-9 and PARP1. In addition, TMEM40 silencing dramatically decreased tumor growth in mice models. CONCLUSION: The present study demonstrates that TMEM40 upregulation can be a potential prognostic biomarker and contribute to CC development.

Hemodialysis nurse burnout in 31 provinces in mainland China: A cross-sectional survey.

INTRODUCTION: Job burnout is an occupational psychological syndrome with a high prevalence among nurses in China. Hemodialysis (HD) nursing work has the characteristics of high intensity, high technical content, and high risk. The aims of this study were to investigate the prevalence and level of job burnout among HD nurses in China and explore the potential factors associated with burnout among HD nurses. METHODS: This was a cross-sectional study in 2019. Survey data were collected from 2738 HD centers in mainland China. Job burnout was measured by the Chinese version of the Maslach Burnout Inventory. The working atmosphere, interpersonal relationships with colleagues, and intention to leave were each assessed by a single question respectively. Multiple linear regression and structural equation modeling were used for the analysis. FINDINGS: A total of 10,570 surveys were collected. A total of 1199 (11.34%) HD nurses reported a high level of emotional exhaustion, 782 (7.40%) reported a high level of depersonalization, and 6767 (64.02%) reported a low level of personal accomplishment. Job burnout in the Northeastern region of mainland China was higher than that in other regions (p < 0.05). The working atmosphere, interpersonal relationships, region, hospital level, educational level, career planning, age, and number of children were significantly associated with burnout among HD nurses (p < 0.001, adjusted R2 = 0.313). The working environment, individual factors, and specialist nurse training were significantly associated with HD nurse burnout and intention to leave (comparative fit index = 0.907; goodness of fit index = 0.930; root mean square error of approximation = 0.055). DISCUSSION: There were notable regional differences in the burnout of HD nurses. This study contributes to the knowledge of the possible relationship of job burnout and intention to leave in HD nurses. It is suggested that improving the working atmosphere or interpersonal relationships and providing more training opportunities can alleviate job burnout in HD nurses.

How to Reduce the Risk of Arteriovenous Fistula Dysfunction by Observing Prepump Arterial Pressure during Hemodialysis: A Multicenter Retrospective Study.

OBJECTIVE: Prepump arterial (Pa) pressure indicates the ease or difficulty with which the blood pump can draw blood from the vascular access (VA) during hemodialysis. Some studies have suggested that the absolute value of the Pa pressure to the extracorporeal blood pump flow (Qb) ratio set on the machine (|Pa/Qb|) can reflect the dysfunction of VA. This study was conducted to explore the impact of arteriovenous fistula (AVF) dysfunction and to explore the clinical reference value of |Pa/Qb|. METHODS: We retrospectively identified adults who underwent hemodialysis at 3 hospitals. Data were acquired from electronic health records. We evaluated the pattern of the association between |Pa/Qb| and AVF dysfunction during 1 year using a Cox proportional hazards regression model with restricted cubic splines. Then, the patients were grouped based on the results, and hazard ratios were compared for different intervals of |Pa/Qb|. RESULTS: A total of 490 patients were analyzed, with an average age of 55 (44, 66) years. There were a total of 85 cases of AVF dysfunction, of which 50 cases were stenosis and 35 cases were thrombosis. There was a U-shaped association between |Pa/Qb| and the risk of AVF dysfunction (p for nonlinearity <0.001). |Pa/Qb| values <0.30 and >0.52 increased the risk of AVF dysfunction. Compared with the group with a |Pa/Qb| value between 0.30 and 0.52, the groups with |Pa/Qb| <0.30 and |Pa/Qb| >0.52 had a 4.04-fold (p = 0.002) and 3.41-fold (p < 0.001) greater risk of AVF dysfunction, respectively. CONCLUSIONS: The appropriate range of |Pa/Qb| is between 0.30 and 0.52. When |Pa/Qb| is <0.30 or >0.52, the patient's AVF function or Qb setting should be reevaluated to prevent subsequent failure.

How to carry out monthly blood flow surveillance of fistula in large-scale hemodialysis units: A cross-sectional study.

BACKGROUND: The important effect of regular blood flow surveillance on arteriovenous fistula maintenance is emphasized. The ultrasonic dilution technique for blood flow surveillance can be performed during hemodialysis, but there are some limitations. Blood flow is traditionally measured by duplex Doppler ultrasound during the nondialysis period. However, the surveillance workload for arteriovenous fistula has increased with the rapid increase in the hemodialysis population size. Efficient methods for blood flow surveillance during hemodialysis are needed. METHODS: Eighty-four hemodialysis patients with a forearm radiocephalic arteriovenous fistula were enrolled in this cross-sectional study. Each received blood flow measurements using ultrasonic dilution technique and duplex Doppler ultrasound during hemodialysis. Duplex Doppler ultrasound measurements included the blood flow of the brachial artery and radial artery. The correlations between these variables were analyzed. RESULTS: The correlation coefficients (r) between flow measured by ultrasonic dilution technique and brachial artery flow measured by duplex Doppler ultrasound, between flow measured by ultrasonic dilution technique and radial artery flow measured by duplex Doppler ultrasound, and between brachial artery flow and radial artery flow measured by duplex Doppler ultrasound were 0.724, 0.784, and 0.749, respectively (all p < 0.001). CONCLUSION: Blood flow measured by ultrasonic dilution technique was positively correlated with blood flow measured by duplex Doppler ultrasound during hemodialysis, suggesting that duplex Doppler ultrasound can be used to monitor the trends in the blood flow of the brachial artery and radial artery for timely intervention to improve patency during hemodialysis.

It is time to implement prepump arterial pressure monitoring during hemodialysis: A retrospective multicenter study.

INTRODUCTION: Prepump arterial pressure (Pa) indicates the ease or difficulty with which the blood pump can draw blood from vascular access (inflow) during hemodialysis. The absolute prepump arterial pressure to blood pump speed (Qb) ratio (|Pa/Qb|) may reflect the dysfunction of other vascular accesses. There is no consensus on the impact of |Pa/Qb| on arteriovenous fistula dysfunction. This study aimed to demonstrate the impact of |Pa/Qb| on arteriovenous fistula dysfunction. METHODS: In this retrospective analysis, 490 hemodialysis patients with arteriovenous fistula from three hospitals were enrolled. Data were extracted from the I-Diapro database and hospital case systems. The absolute values for |Pa/Qb| and other data collected in the first month of enrollment were used to predict arteriovenous fistula dysfunction and determine the |Pa/Qb| cutoff value. Based on this value, patients were grouped, and 1-year arteriovenous fistula function was analyzed. Patients were followed until arteriovenous fistula dysfunction, until access type replacement, or for 12 months. RESULTS: The area under the receiver operating characteristic curve for fistula dysfunction over 1 year was 0.65, with an optimal |Pa/Qb| value, sensitivity, and specificity of 0.499, 60.7%, and 72.6%, respectively. |Pa/Qb| > 0.499 was associated with earlier intervention (317.37 ± 7.68 vs 345.96 ± 3.64 days), lower survival (p < 0.001), and a 3.26-fold greater risk of arteriovenous fistula dysfunction (p < 0.001) than |Pa/Qb| ⩽ 0.499. CONCLUSIONS: |Pa/Qb| was an independent risk factor for arteriovenous fistula dysfunction. Nurses should emphasize |Pa/Qb| monitoring and properly set blood pump speed according to this ratio to protect arteriovenous fistula function. |Pa/Qb| > 0.499 might be a predictive measure of arteriovenous fistula dysfunction.

Effect of Dumbbell Exercise on Arteriovenous Fistula in Patients Undergoing Maintenance Haemodialysis: A Prospective Randomized Controlled Trial.

BACKGROUND: Arteriovenous fistulas (AVF) have been the main vascular accesses for haemodialysis patients, but the maintenance after maturation poses serious challenges. Arm exercises promote the maturation of AVFs. However, few studies have evaluated the effect of arm exercise on matured AVF and addressed the intervention for late fistula failure. OBJECTIVES: The study was conducted to explore the effect of dumbbell exercise on mature AVF. METHODS: 86 participants undergoing haemodialysis with AVFs were randomized into the control group and experimental group. The experimental group held 6-pound dumbbells on non-dialysis days for 3 months, while the control group squeezed rubber balls. RESULTS: For blood flow of draining vein (DV; primary outcome), the between-group effects, interaction effect and time effect showed significant differences. A significant increase in blood flow of DV was observed in the dumbbell group at the 3rd month (mean difference, 359.50 [111.90-829.05] mL/min; p = 0.001). The difference in blood flow of AVF proximal artery, blood flow of brachial artery, the diameter of DV and the incidence of adverse events at 3 months (secondary outcomes) between the 2 groups was insignificant. CONCLUSION: Prolonged training with arm exercises is essential for patients with AVFs though the fistula has matured. The designed dumbbell exercise is an economical, effective intervention to maintain the function of AVF, especially for patients with potential reduction of access blood flow and no percutaneous transluminal angioplasty indication.

Can the fistula arm be used to lift heavy items? Six-pound dumbbells versus handgrip exercise in a 6-month follow-up secondary analysis of a randomized controlled trial.

INTRODUCTION: Patients with arteriovenous fistulas are advised to avoid carrying heavy objects draped over the fistula arm. Awareness gradually leads to overprotection and a reduction in the use of the fistula arm. However, restricting motion in the fistula arm leads to decreased quality of life and diminished muscle strength. The current safety recommendations regarding lifting heavy items with the fistula arm are primarily based on experience. Few studies have provided evidence clarifying the scope of safe activity and the influence of load bearing on the continued patency of arteriovenous fistulas. METHODS: This prospective observation was based on a long-term follow-up study in which 86 hemodialysis recipients with arteriovenous fistulas were randomized into either a dumbbell group or a handgrip group. The dumbbell group exercised with 6-lb dumbbells, while the handgrip group squeezed rubber balls. Postintervention primary patency and adverse events at the 6-month follow-up were analyzed. RESULTS: No significant difference in postintervention primary patency was observed between the dumbbell group and the handgrip group at 6 months (97.4% vs 95.0%). There were two participants with high-flow fistulas in the dumbbell group and three in the handgrip group, with no significant difference between the two groups (5.3% vs 7.5%). In both groups, there were no other adverse events reported regarding cardiac failure, aneurysm, puncture site hematoma, or hemorrhage. CONCLUSION: Hemodialysis patients can safely use their fistula arm to lift objects weighing less than 6 lb, which encourages increased motion and helps preserve the functionality of the fistula arm.

Effect of aerobic exercise intervention on DDT degradation and oxidative stress in rats.

Dichlorodiphenyltrichloroethane (DDT) reportedly causes extensively acute or chronic effects to human health. Exercise can generate positive stress. We evaluated the effect of aerobic exercise on DDT degradation and oxidative stress. MAIN METHODS: Male Wistar rats were randomly assigned into control (C), DDT without exercise training (D), and DDT plus exercise training (DE) groups. The rats were treated as follows: DDT exposure to D and DE groups at the first 2 weeks; aerobic exercise treatment only to the DE group from the 1st day until the rats are killed. DDT levels in excrements, muscle, liver, serum, and hearts were analyzed. Superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px), and malondialdehyde (MDA) levels were determined. Aerobic exercise accelerated the degradation of DDT primarily to DDE due to better oxygen availability and aerobic condition and promoted the degradation of DDT. Cumulative oxidative damage of DDT and exercise led to significant decrease of SOD level. Exercise resulted in consistent increase in SOD activity. Aerobic exercise enhanced activities of CAT and GSH-Px and promoted MDA scavenging. Results suggested that exercise can accelerate adaptive responses to oxidative stress and activate antioxidant enzymes activities. Exercise can also facilitate the reduction of DDT-induced oxidative damage and promoted DDT degradation. This study strongly implicated the positive effect of exercise training on DDT-induced liver oxidative stress.