Citations

Abstract Background Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus species, commonly observed in patients with asthma or cystic fibrosis. However, its occurrence in individuals with chronic obstructive pulmonary disease (COPD) is rare and not well-documented. Radiological findings such as the "finger-in-glove" sign on computed tomography (CT) scans can aid in diagnosis, but a high index of suspicion is required in atypical cases. ABPA can contribute to mucoid impaction, leading to progressive pulmonary dysfunction if left untreated. Case Presentation We report a unique case of ABPA in a patient with COPD who had no prior history of asthma or cystic fibrosis. The patient presented with worsening respiratory symptoms, and imaging studies revealed mucoid impaction with the characteristic "finger-in-glove" sign. Laboratory findings included peripheral eosinophilia and elevated serum IgE, supporting the diagnosis of ABPA. Management involved antifungal therapy and corticosteroids, followed by a tapering regimen, with prophylactic treatment for pneumocystis pneumonia (PCP) to prevent opportunistic infections. Follow-up pulmonary function tests demonstrated a moderate decline in diffusion capacity, necessitating continued monitoring for potential early interstitial lung disease (ILD) or pulmonary hypertension. Conclusions This case highlights the importance of considering ABPA in patients with COPD who present with mucoid impaction, even in the absence of traditional risk factors. A thorough differential diagnosis of eosinophilia in pulmonary disease is crucial to distinguish between hypersensitivity reactions and malignant myeloproliferative disorders, ensuring appropriate treatment strategies. Clinicians should maintain a high level of awareness for ABPA in COPD patients to facilitate timely diagnosis and management.

Abstract Hospital medicine (HM), a well‐established clinical specialty, requires clarity of research priorities to identify target areas for investment in HM research infrastructure and activities. The Society of Hospital Medicine's Research Committee developed a 20‐item survey and used purposeful sampling of US hospitalist leaders to prioritize primary research topic domains and subdomains. Respondents were asked to rank their HM research priorities using a scale (1 [highest] to 8 [lowest]). Of 239 surveys distributed, 81 (34%) responded. Respondents were predominantly White (53%) and from academic institutions (57%). “ Overall, 46% of respondents were male and 33% were female. ” Top‐ranked research domains were innovation in care delivery (median 2, IQR 1,3), value‐based care (median 3.5, IQR 2,6), and health disparities (median 4, IQR 2,5). This survey identified top HM research priorities including systems‐based topics and health disparities, aligning with HM's identity as a specialty focused on improving systems of care and inequities in care.

Objective: We aimed to analyze the current literature for IORT in gynecological cancers and summarized clinical outcomes regarding patient selection. Methods: A systematic search was conducted utilizing PUBMED, Embase, and CINAHL to identify studies following PRISMA-ScR guidelines. A PICOS structure was utilized: population: patients with epithelial gynecological cancers; intervention: IORT; C: a comparator was not required, as we aimed to analyze patient selection; outcome: clinical outcomes and overall survival; and S: experimental and quasi-experimental analytical observational studies and descriptive observational studies, excluding case series published in English and limited to the last 10 years. Data extraction was conducted for patient selection, IORT, oncological outcomes, and morbidity. Results: A total of 707 results were identified, and 509 studies were uploaded to Covidence for screening after removing duplications. Of the 21 eligible studies, 9 were included in the final review. The total number of patients included was 348. The studies were retrospective single-institution studies, except for one. There was significant heterogeneity in their design and protocols. IORT was exclusively used for recurrent and advanced stage gynecological cancers adjunct to pelvic exenteration or laterally extended endopelvic resections with variable indications across institutions. The mean number of IORT patients per study was 2.8 per year. Survival rates were variable and dependent on the surgical margin. Endometrial cancer had a favorable outcome compared to vulvar and cervical cancers. Conclusions: Current clinical practice, as demonstrated by the research, is consistent with NCCN guidelines that endorse the application of IORT in instances of recurrent cervical, vaginal, and vulvar malignancies; however, there are no established recommendations for primary tumors. The analysis shows that there are gaps in our knowledge, mainly regarding the status of the margins, the criteria used to choose patients, and the outcomes that are specific to each histology. The standardization of protocols and prospectively powered studies are needed to refine patient selection criteria.

Background Severe alcohol-associated hepatitis (sAH) is a life-threatening condition with high mortality, where corticosteroid use is the only treatment that has shown short-term benefits. Pentoxifylline, an anti-tumour necrosis factor-alpha agent, has been proposed for its potential to improve outcomes, especially in patients with acute kidney injury (AKI). We aimed to evaluate the impact of pentoxifylline on mortality in patients with sAH and AKI in a well-characterised global cohort. Methods We conducted a retrospective, registry-based study including patients meeting the National Institute on Alcohol Abuse and Alcoholism clinical criteria for sAH and AKI. Mortality was the primary endpoint, with liver transplantation as a competing risk. Statistical analysis included Cox regression and Kaplan-Meier survival estimates. Results We included 525 patients from 20 centres across eight countries. The median age was 48 years, with 26.1% females, and 76.9% had a history of cirrhosis. Multivariable Cox regression models showed that pentoxifylline use was not associated with survival (HR 1.20, 95% CI 0.85 to 1.69, p=0.291). Factors associated with mortality included age (HR 1.23, 95% CI 1.10 to 1.36, p<0.001), Model for End-Stage Liver Disease score at admission (HR 1.06, 95% CI 1.04 to 1.08, p<0.001) and renal replacement therapy use (HR 1.39, 95% CI 1.05 to 1.84, p=0.019). The main causes of death were multiple organ failure (42%), infections (10%), oesophageal varices bleeding (7%) and renal failure (6%). Conclusion Pentoxifylline showed no significant benefit on mortality in patients with sAH and AKI. Further studies are needed to refine treatment strategies for this high-risk group.

ABSTRACTBackgroundComparisons of outcomes after transcatheter aortic valve replacement with balloon‐expandable (BEV) versus self‐expanding (SEV) valves are limited.HypothesisThis study aimed to compare clinical and hemodynamic outcomes of BEV and SEV at short‐term (30 days), midterm (1 year), and long‐term (> 1 year) endpoints.MethodsPubMed, Embase, Scopus, and Cochrane Library databases were searched until July 2024 for randomized controlled trials. Random‐effect model (DerSimonian–Laird method) was used to pool the risk ratios (RR), mean differences, and 95% confidence intervals (CI).ResultsA total of 10 studies comprising 4325 patients (2295 BEV, 2030 SEV) were included. In short‐term, cardiovascular (RR: 0.56, 95% CI: 0.36–0.87) and all‐cause mortality (RR: 0.54, 95% CI: 0.35–0.81) were lower in the BEV group. Risk of moderate to severe paravalvular leak (PVL) was lower among BEV patients in short‐term (RR: 0.28, 95% CI: 0.17–0.49) and long‐term (RR: 0.28, 95% CI: 0.1–0.79). A limited number of studies showed a greater risk of clinical valve thrombosis on BEV in midterm and long‐term. The need for permanent pacemaker implantation was lower in BEV at both short‐term (RR: 0.56, 95% CI: 0.37–0.87), and midterm (RR: 0.78, 95% CI: 0.64–0.94). The SEV group had a larger effective orifice area with lower mean transvalvular pressure gradient at all endpoints.ConclusionsBEV is associated with reduced risk of clinical outcomes in short‐term; however, most differences diminish in longer evaluations, except for moderate to severe PVL, which remains elevated for SEV. SEVs had better hemodynamic results and lower risk of clinical valve thrombosis.

Background: End-stage ankle arthritis is successfully treated with surgery with either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). Much is described comparing the 2 treatments in tightly selected patient groups. Limited evidence attempts to examine specific elements of technical complexity that increase perioperative risk for the surgical treatment of ankle arthritis. There is suspicion that AA may be preferable in the setting of elevated patient complexity, or that procedures may require staging to diminish complication risk when there is also foot deformity present. The aim of this study is to evaluate the effect of adjunctive procedures on overall postoperative complication (POC) risk, for both TAA and AA. Primary outcome measures were to compare overall complication and reoperation risk for TAA and AA. Secondary outcome measures were to identify patient factors, intraoperative factors, and factors of procedural complexity via number of associated surgeries and the incidence of complications and reoperation. Methods: A retrospective chart review of AAs and TAAs performed at a single academic institution from the years 2008-2024 was performed using Current Procedural Terminology ( CPT ) codes identifying AA and TAA. Patient demographics, operative details, and postoperative data were abstracted to collect relevant information. Statistical analyses, including odds ratios and analysis of variance, were then performed to reveal specific risk factors and correlations. Results: Four hundred ninety-one patients were identified in the initial database query. After exclusions, 246 remained, of which 110 underwent AA and 136 underwent TAA. The mean length of follow-up was 36.4 months for TAA patients and 46.1 months for AA patients in this study. Overall, patients who underwent TAA were older and had an increased number of preoperative comorbidities (5.74 ± 3.07) compared to AA (4.74 ± 2.76) ( P = .008). Additionally, TAA patients experienced a lower overall rate of POCs (20/136, 14.71%) and reoperation (14/136, 10.29%) compared with patients who underwent AA (21/110, 19.09%; 21/110, 19.09%) ( P = .36 and P = .05, respectively). As the number of adjunctive procedures increased, so did the rate of POCs, but not reoperation, in patients who underwent TAA. The number of adjunctive procedures was not significantly associated with complication or reoperation risk in AA patients. There were no specific adjunctive procedures that demonstrated a significant correlation with increased risk of complications or reoperation in both groups. Osteoporosis and coagulopathies were identified as predisposing TAA patients to postoperative complications. Conclusion: In our retrospective cohort study with relatively low statistical power, we found that patients who undergo TAA or AA plus adjunctive procedures did not experience an increased risk of major complications or reoperation compared to patients who did not undergo adjunctive procedures. Several preexisting comorbidities in TAA patients were associated with higher rates of POCs or reoperation, including osteoporosis and coagulopathies; no comorbidities were linked to increased reoperation or POC risk in the AA group. These findings suggest a need to evaluate comorbidities, and lifestyle factors when recommending an ankle reconstruction procedure to minimize the odds of postoperative complications and improve likelihood of patient satisfaction. Level of Evidence: Level III, retrospective cohort study.

ABSTRACTVenous leg ulcers (VLUs) are traditionally managed with standard‐of‐care dressings, compression and appropriate adjunctive venous interventions for pathologic venous reflux. Due to pathophysiological complexity and underlying patient comorbidities, conducting randomised controlled trials to evaluate the comparative efficacy of advanced treatment modalities is difficult, as many patients would likely be excluded. This retrospective, pragmatic, real‐world evidence (RWE) study compared the healing outcomes of VLUs treated with either ovine forestomach matrix (OFM) (n = 312) or collagen/oxidised regenerated cellulose (ORC) (n = 239) in outpatient wound care centres. Unlike restrictive randomised controlled trials, minimal inclusion and exclusion criteria were applied to create two treatment cohorts that reflected the general VLU population. The incidence (%) of closure was greater in OFM‐treated VLUs at 12, 24 and 36 weeks, and this difference was significant at 24 and 36 weeks compared to collagen/ORC. Median time to wound closure was significantly faster (p = 0.045) in the OFM cohort (11.1 ± 0.6 weeks) compared to the collagen/ORC group (12.3 ± 1.0 weeks). Cox proportional hazards analysis demonstrated that OFM‐treated VLUs had a significantly greater probability of healing (up to ~40%). This RWE comparative efficacy study further substantiates the clinical benefit of OFM in the treatment of chronic wounds, such as VLU, in a real‐world patient cohort.

ABSTRACT HLA‐B*38:125 differs from HLA‐B*38:02:01:01 by one nucleotide substitution in codon 248 (GTG>ATG) in exon 4.

ABSTRACT Background Membranous nephropathy (MN) is a leading cause of nephrotic syndrome (NS). Since the identification of anti–phospholipase A2 receptor (anti-PLA2R) antibodies in 2009, the use of laser microdissection and tandem mass spectrometry (LMD/MS) has allowed the discovery of several target antigens in MN. Methods In this retrospective cohort study, adult patients evaluated at the Division of Nephrology at Brotzu Hospital (Cagliari, Italy) with biopsy-proven MN and a negative serological test for anti-PLA2R antibody underwent LMD/MS, performed at the Department of Laboratory Medicine and Pathology of Mayo Clinic (Rochester, MN, USA). Results Twenty-four cases of biopsy-proven MN were available for antigen detection by LMD/MS studies. High total spectral counts of PLA2R were detected in 12 out of 24 (50%) cases. In addition, high spectral counts of THSD7A and NELL1 were detected in two cases each, and EXT1/EXT2 and NCAM1 in one case each. Five putative antigens have been detected: SULF1, PGLYRP, HYAL1, THBS and SEZ6L2. Conclusions Our study highlights at least two interesting considerations. First, the determination of PLA2R on renal tissue in the diagnosis of PLA2R-associated MN is emphasized since 50% of our cases were falsely diagnosed with PLA2R-negative MN based on the serum anti-PLA2R antibodies determination. Second, our study shows six patients with MN likely associated with putative antigens, two of them showing new antigens never described before in literature (HYAL1 and THBS1). This high prevalence of putative antigens in our cohort is not easily explainable and paves the way for evaluating specific factors in the Sardinian population that could explain this evidence.