The many faces of brucellosis: diagnostic and management approach.

PURPOSE OF REVIEW: This review aims to highlight the multifaceted nature of brucellosis, emphasizing the latest advancements in its diagnosis and management. Given the global prevalence and potential complications of brucellosis, understanding recent advancements in diagnostic techniques and treatment strategies is crucial for clinicians. RECENT FINDINGS: Recent literature reveals significant progress in diagnostic methods, including the application of fluorescence polarization immunoassay and time-resolved fluorescence resonance energy transfer technologies as well as the invention of artificial Brucella antigens, which offer enhanced sensitivity and specificity. Advances in molecular diagnostics and serological tests have improved early detection rates, however their interpretation remains challenging. Evolving treatment regimens such as the use of hydroxychloroquine as part of triple therapy and the use of nano-delivery systems in therapies have shown promise, in hopes of reducing relapse rates and managing chronic cases. SUMMARY: The findings underscore the necessity for clinicians to adopt a comprehensive approach to diagnosing and managing brucellosis. Integrating advanced diagnostic tools with tailored therapeutic strategies can significantly improve patient outcomes. Future research should focus on optimizing these diagnostic techniques and exploring novel therapeutic agents.

Ibrexafungerp: A narrative overview.

Ibrexafungerp (IBX) is a new antifungal drug that recently entered the antifungal landscape. It disrupts fungal cell wall synthesis by non-competitive inhibition of the ß-(1,3)-D-glucan (BDG) synthase enzyme. It has demonstrated activity against a range of pathogens including Candida and Aspergillus spp., as well as retaining its activity against azole-resistant and echinocandin-resistant strains. It also exhibits anti-biofilm properties. Pharmacokinetic (PK) studies revealed favorable bioavailability, high protein binding, and extensive tissue distribution with a low potential for CYP-mediated drug interactions. It is characterized by the same mechanism of action of echinocandins with limited cross-resistance with other antifungal agents. Resistance to this drug can arise from mutations in the FKS genes, primarily FKS2 mutations in Nakaseomyces glabrata. In vivo, IBX was found to be effective in murine models of invasive candidiasis (IC) and invasive pulmonary aspergillosis (IPA). It also showed promising results in preventing and treating Pneumocystis jirovecii infections. Clinical trials showed that IBX was effective and non-inferior to fluconazole in treating vulvovaginal candidiasis (VVC), including complicated cases, as well as in preventing its recurrence. These trials positioned it as a Food and Drug Administration (FDA)-approved option for the treatment and prophylaxis of VVC. Trials showed comparable responses to standard-of-care in IC, with favorable preliminary results in C. auris infections in terms of efficacy and tolerability as well as in refractory cases of IC. Mild adverse reactions have been reported including gastrointestinal symptoms. Overall, IBX represents a significant addition to the antifungal armamentarium, with its unique action, spectrum of activity, and encouraging clinical trial results warranting further investigation.

Recent advances in the treatment of Ebola disease: A brief overview.

Ebola disease (EBOD) remains a significant and ongoing threat to African countries, characterized by a mortality rate of 25% to 90% in patients with high viral load and significant transmissibility. The most recent outbreak, reported in Uganda in September 2022, was declared officially over in January 2023. However, it was caused by the Sudan Ebola virus (SUDV), a culprit species not previously reported for a decade. Since its discovery in 1976, the management of EBOD has primarily relied on supportive care. Following the devastating outbreak in West Africa from 2014 to 2016 secondary to the Zaire Ebola virus (EBOV), where over 28,000 lives were lost, dedicated efforts to find effective therapeutic agents have resulted in considerable progress in treating and preventing disease secondary to EBOV. Notably, 2 monoclonal antibodies-Ebanga and a cocktail of monoclonal antibodies, called Inmazeb-received Food and Drug Administration (FDA) approval in 2020. Additionally, multiple vaccines have been approved for EBOD prevention by various regulatory bodies, with Ervebo, a recombinant vesicular stomatitis virus-vectored vaccine against EBOV being the first vaccine to receive approval by the FDA in 2019. This review covers the key signs and symptoms of EBOD, its modes of transmission, and the principles guiding supportive care. Furthermore, it explores recent advancements in treating and preventing EBOD, highlighting the unique properties of each therapeutic agent and the ongoing progress in discovering new treatments.

Metallo-beta-lactamases: mechanisms, treatment challenges, and future prospects.

INTRODUCTION: Metallo-beta-lactamases (MBLs) are responsible for resistance to almost all beta-lactam antibiotics. Found predominantly in Gram-negative bacteria, they severely limit treatment options. Understanding the epidemiology, risk factors, treatment, and prevention of infections caused by MBL-producing organisms is essential to reduce their burden. AREAS COVERED: The origins and structure of MBLs are discussed. We describe the mechanisms of action that differentiate MBLs from other beta-lactamases. We discuss the global epidemiology of MBL-producing organisms and their impact on patients' outcomes. By exposing the mechanisms of transmission of MBLs among bacterial populations, we emphasize the importance of infection prevention and control. EXPERT OPINION: MBLs are spreading globally and challenging the majority of available antibacterial agents. Genotypic tests play an important role in the identification of MBL production. Phenotypic tests are less specific but may be used in low-resource settings, where MBLs are more predominant. Infection prevention and control are critical to reduce the spread of organisms producing MBL in healthcare systems. New combinations such as avibactam-aztreonam and new agents such as cefiderocol have shown promising results for the treatment of infections caused by MBL-producing organisms. New antibiotic and non-antibiotic agents are being developed and may improve the management of infections caused by MBL-producing organisms.

Sexual and reproductive health knowledge among adolescent Syrian refugee girls displaced in Lebanon: The role of schooling and parental communication.

Adolescent Syrian refugee girls living in Lebanon are vulnerable to poor sexual and reproductive health (SRH). Sociocultural norms, stigmatization, and limited educational opportunities in the context of forced displacement may impact adolescent girls' SRH. Little is known about how and where girls in this population access SRH information and services. This study aimed to: (1) assess knowledge of SRH topics among a population of adolescent Syrian refugee girls displaced in Lebanon, and (2) determine the association of schooling versus maternal SRH communication with SRH knowledge. A total of 418 11-17-year-old Syrian refugee girls displaced in the Beqaa region of Lebanon were recruited to participate in a cross-sectional survey. Bivariate logistic regression and ordinary least squares regression models were used to examine the associations between schooling, maternal SRH communication, and other covariates with SRH knowledge outcomes. Significant predictors (p<0.2) were included in multivariate analyses. The mean age of girls was 13.4 years. Approximately two thirds of our sample was enrolled in school, with enrollment rates dropping considerably around age 15. In bivariate and multivariate models, older age and participation in SRH programs were predictive of puberty knowledge. One in five girls enrolled in school had learned about menstruation in school, which was associated with higher puberty knowledge in bivariate models. Older age, current school enrollment, and reaching the 8th-11th grade were strongly associated with HIV knowledge. Schooling is more strongly associated with SRH knowledge among adolescent girls than is maternal communication. School-based SRH curricula should be administered on the basis of age and not grade, given significant age-for-grade heterogeneity in this population. Forced displacement and poverty are major barriers to education retention and may have long-term impacts on girls' health.

Sexual and Reproductive Health Information and Experiences Among Syrian Refugee Adolescent Girls in Lebanon.

Providing adolescent girls with sexual and reproductive health (SRH) information protects them from risks and improves their well-being. This qualitative study, conducted in Lebanon, examined Syrian refugee adolescent girls' access to SRH information about and experiences with puberty and menarche, sex, marriage, contraception, and pregnancy. We gathered data through three focus group discussions (FGDs) with unmarried adolescent girls, 11 in-depth interviews with early-married adolescents, and two FGDs with mothers. Our findings highlighted that adolescent participants received inadequate SRH information shortly before or at the time of menarche and sexual initiation, resulting in experiences characterized by anxiety and fear. They also revealed discordance between girls' views of mothers as a preferred source of information and mothers' reluctance to communicate with their daughters about SRH. We advance that mothers are important entry points for future interventions in this refugee population and offer recommendations aimed to improve adolescent girls' SRH and rights.

Survival, functional capacity, and quality of life after cardiac surgery followed by long-term intensive care stay.

BACKGROUND: The rising prevalence of multimorbid patients undergoing cardiac surgery often leads to prolonged postoperative intensive care unit (ICU) treatment. The fate of these patients after discharge is poorly investigated. This study is aimed to assess survival, functional outcome, and quality of life (QOL) in patients after an ICU stay of at least 5 days. MATERIALS AND METHODS: Between August 2009 and July 2010, 1,092 patients underwent various cardiac procedures. Of these patients, 119 required ICU treatment of at least 5 days. Preoperative characteristics as well as postoperative course were analyzed and the discharged patients were contacted after 1 year to gain information about survival, functional capacity, and QOL. RESULTS: European system for cardiac operative risk evaluation I of the patients was 22.3 ± 16.7. Mean ICU stay was 19 ± 20 days. Forty three patients (36.1%) died in the hospital, 1-year overall survival was 46.2%, and 1-year survival of the discharged patients was 72.4%. Barthel mobility index was 85, showing a satisfactory mobilization. QOL, assessed with short form 12 questionnaire, was comparable with the reference group. CONCLUSION: Long-term ICU treatment after cardiac surgery is related to a high in-hospital and follow-up mortality. The physical and psychological recovery of the survivors is encouraging, justifying the extensive engagement of hospital resources.

Reduction in blood product usage associated with routine use of mini bypass systems in extracorporeal circulation.

OBJECTIVE: The objective of this study is to investigate the hypothesis that a reduced prime extracorporeal circulation (ECC) system and ensuing reduction in patient hemodilution can affect blood product use. METHODS: We performed a prospective, randomized study from a group of 60 consecutive coronary artery bypass graft (CABG) patients, comparing blood product usage and postoperative bleeding in 30 mini bypass systems (n = 30) to 30 conventional systems (n = 30). The patient demographics in terms of patient weight, height, age, preoperative hemoglobin, preoperative hematocrit, BSA, ejection fraction, and NYHA were not statistically significant. RESULTS: Blood product use, including fresh frozen plasma (FFP) and homolgous blood transfusions was tracked through the operating theater and into the intensive care unit. In the mini bypass group, while no homologous blood transfusions were given in the OR, 27% of the patients received at least one unit of homologous blood. In the control group, 43% of the patients received at least one unit of blood in the OR or in the ICU and there was a stastistically-significant 38% reduction in homologous blood product use (p = 0.05). For the patients who received homologous blood, there was also a significant reduction in transfused volume (0.53 +/- 0.90 units blood mini bypass vs 1.3 +/- 1.93 units conventional, p < 0.05). In terms of FFP, there was also a stastistically significant difference between the two groups (0 units transfused in mini bypass group vs 3 patients receiving one unit FFP in the control group, p < 0.001). Cumulative postoperative bleeding during the ICU stay was also evaluated, yielding a significant reduction (365 +/- 495 ml mini bypass vs 825 +/- 975 ml conventional, p < 0.05). CONCLUSION: Mini bypass reduces on-pump hemodilution and, therefore, donor blood usage in routine CABG patients as compared to conventional ECC circuits and can reduce postoperative bleeding as compared to a traditional system. The mini bypass system is safe in routine clinical use and can manage easily the same number of anastomoses as a traditional system and should be considered a favorable alternative to conventional ECC in all revascularization cases.

[Anterior radial nerve transposition in humerus midshaft fractures: anatomic and clinical study]. / Transposition antérieure du nerf radial dans les fractures du 1/3 moyen de l'humérus: bases anatomiques et applications cliniques.

PURPOSE OF THE STUDY: Plate fixation of midshaft humerus fractures raises the risk of radial nerve injury. Anterior transposition of the radial nerve has been proposed as a possible solution but few reports have been published. The purpose of the present study was to validate the effect of transposition on the transposed radial nerve and its branches. MATERIAL AND METHODS: We conducted an anatomic study on 10 cadavers. The length of the radial nerve between 2 anatomic landmarks was determined before and after transposition and plate fixation. A clinical evaluation was performed four years after surgery in 6 patients with midshaft humerus fractures treated with plate fixation after radial nerve transposition. RESULTS: The anatomic study demonstrated a mean gain of 11 mm in the length of the radial nerve with no problem for the transposed nerve or its branches. Clinically, osteosynthesis was facilitated and tension on the nerve was reduced. DISCUSSION: These 2 complementary studies demonstrated the releasing effect of transposition on the radial nerve and the facilitated osteosynthesis reported by others. The benefit of transposition is particularly important when bone fixation is particularly difficult to achieve without risk of injuring the radial nerve. Transposition does however require an extensive dissection, and the patient must be informed. CONCLUSION: The ideal indication for anterior transposition of the radial nerve is an oblique fracture of the mid-third to lower-third of the humeral shaft with radial palsy at onset. A certain degree of comminution facilitates the technique. Indications for this technique could however be widened to include cases of difficult osteosynthesis where the option to transpose the radial nerve is always a peroperative decision.

Impact of high intensity transient signals on the choice of mechanical aortic valve substitutes.

OBJECTIVE: High intensity transient signals (HITS) observed during extracorporeal circulation and following mechanical valve replacement are suspected of causing cognitive dysfunction (deterioration of episodic and working memory). This study evaluates the role played by valve design (bileaflet versus tilting disc) and other parameters in the incidence of HITS. METHODS: Thirty patients were selected for the study as follows: 18 males, 58-78 years of age; ten St. Jude Medical, ten CarboMedics, ten Medtronic Hall (MH); all size 23, in optimum orientation (Ann Thorac Surg 68 (1999) 1069); all in sinus rhythm; no coronary or carotid artery disease; all in sinus rhythm, international normalized ratio greater than 2.5 and all at least 9 months postoperative. All patients had bilateral HITS measurement in both middle cerebral arteries via transcranial doppler for 30 min. If five HITS or more were observed during the initial 10 min, patients were subjected to 100% oxygen breathing followed by 10 min of normal air breathing. Simultaneously, HITS were measured in the right radial and femoral arteries. RESULTS: Patients with bileaflet valve substitutes revealed HITS rates varying from 32 to 108 counts/h. There was only one HITS observed in the MH valve group during the 5h observation period (0.2 HITS/h). There were no HITS detected in either the radial or the femoral arteries in any patient. After breathing 100% oxygen, HITS significantly decreased or completely disappeared (0-30 HITS/h). When normal air breathing was resumed HITS reappeared or increased. With an intravenous infusion of 100 mg of lysine acetylsalicylate (Aspisol, Bayer Leverkusen, Germany), HITS decreased by 16 to 41%. CONCLUSIONS: We conclude that bileaflet mechanical valve prostheses produce HITS even in their optimum orientation. HITS following bileaflet valve replacement have an unstable nature and might be composed of nitrogen and platelets. Tilting disc valves in their optimum orientation provide almost physiological conditions with HITS measured in the same range as bioprosthesis.

Symptomatic palmaris longus muscle variation with MRI and surgical correlation: report of a single case.

A young woman presented with a painful soft tissue swelling of the anterior aspect of the distal forearm. MRI revealed a hypertrophied reversed palmaris longus muscle confirmed by surgery, which also showed a second insertion to the flexor carpi radialis tendon. Variants of the palmaris longus muscle are discussed.

[Unstable fractures of the distal radius: a new classification]. / Instabilité des fractures de l'extrémité inférieure du radius: classification analytique à visée thérapeuthique.

We have carried out a retrospective study of 100 fractures of the distal radius which were classified according to 3 principal factors, namely the amount of displacement (D), the involvement of the epiphysis (E), and the degree of metaphyseal comminution (M). Each of these 3 groups was further divided into 4 levels of increasing instability. The fractures were assessed 3 months after injury. Most occurred in old patients with low grades in the DEM scale, often in association with osteoporosis and following a simple fall. Metaphyseal comminution and the degree of displacement did not correlate with the degree of osteoporosis. The highest grades of epiphyseal lesions occurred in young patients, and intact epiphyses were seen in the more osteoporotic population. The Kapandji technique, using 3 Kirschner wires, was used in 58 cases, mostly with low grades of DEM, and gave satisfactory results, but in 14% anterior carpal translation was noted. This may lead to anterior instability. External fixation was employed in 32 patients with higher grade fractures. A good anatomical result was usually obtained but the wrists were more stiff. In 7 of these patients fixation of articular fragments by wires was also needed. Reduction and immobilisation in a cast was undertaken in 7 cases with variable results. Double cortical pinning was used in 3 patients and was useful in the highest grades of displacement. We outline a scheme for treatment based on our classification.

[Effect of early mobilization following Kapandji's method of intrafocal wiring in fractures of the distal end of the radius. Results of a prospective study of 60 cases]. / Influence de la mobilisation précoce après embrochage intra-focal selon Kapandji dans les fractures de l'extrémité inférieure du radius. Résultats d'une étude prospective sur 60 cas.

We have undertaken a prospective study of the management of fractures of the distal radius using three Kirschner wires as advocated by Kapandji. 30 were immobilised and the other 30 allowed early movement. Complications involving pin migration and rupture of extensor tendons occurred only in the latter group, and one patient in the other group developed Reflex Sympathetic Dystrophy. At three months there was no statistically significant difference in movement or level of pain between the two groups. Grip was better after two months in those mobilised early. The final radiographic appearances were similar in both groups. Early mobilisation should only be used in patients who have good quality bone and will carefully observe instructions after operation.