Diagnostic Challenge in a Patient Presenting with Ascites and Hypergammaglobulinemia

Ascites is defined as the accumulation of intra-peritoneal fluid that can be caused by several diseases. We described a 47-year-old female presenting with low serum-ascites albumin gradient (SAAG) and a markedly high level of serum globulin. Serum protein electrophoresis revealed an M spike in the gamma region. Other laboratory results showed a marked increase in aspartate aminotransferase and alanine aminotransferase and predominantly conjugated hyperbilirubinemia without a sign of dilatation of bile ducts from abdominal ultrasonography examination. Furthermore, the follow-up showed a positive result for the anti-nuclear antibody test. The patient was assessed with autoimmune hepatitis, and the cause of ascites was suggested from portal hypertension although the level of SAAG was low. The ascites condition got improved after salt restriction, diuretics treatment, and abdominal paracentesis. However, the patient passed away because of the intracranial hemorrhage as a result of prolonged INR and APTT due to liver failure.

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Dynamics of antimalarial antibodies in non-immune patients during and after a first and unique P. falciparum malaria episode

10.21203/rs.2.24522/v1 ◽

2020 ◽

Author(s):

Zeno Bisoffi ◽

Marco Bertoldi ◽

Ronaldo Silva ◽

Giulia Bertoli ◽

Tamara Ursini ◽

...

Keyword(s):

Blood Donors ◽

Travel Medicine ◽

Antibody Test ◽

Malaria Episode ◽

Full Blood Count ◽

Case Report Form ◽

Retrospective Diagnosis ◽

Laboratory Test Results ◽

High Level

Abstract BackgroundMalaria is a major travel medicine issue. Retrospective confirmation of a malaria episode diagnosed in an endemic area can have relevant implications in trasfusional medicine in Europe, where blood donors are excluded from donation on the basis of positive malaria serology. However, there is scarce evidence on the dynamics of antimalarial antibodies after a first malaria episode in non immune individuals. First aim of this study was to describe the dynamics of antimalarial antibodies in a first malaria episode in non immune travellers. Secondary objectives were to assess the sensitivity of serology for a retrospective diagnosis in non immune travellers diagnosed while abroad and to discuss the implications in transfusional medicine.MethodsRetrospective analysis of the results of an indirect fluorescence antibody test (IFAT) for malaria available for patients with a first malaria episode by Plasmodium falciparum and admitted at the IRCCS Sacro Cuore Don Calabria hospital in a 14-year period. The antibody titres were collected at baseline and during further follow up visits. Epidemiological, demographic and laboratory test results (including full blood count and malaria parasite density) were anonymously recorded in a study specific electronic Case Report Form created with OpenClinica software. Statistical analysis was performed with SAS software version 9.4. ResultsThirty-six patients were included. Among them, all but two were Europeans (one African and one American). Median length of fever before diagnosis was two days (IQR 1-3). Thirty-five patients had seroconversion between day 1 and day 4 from admission, and the titre showed a sharply rising titre, often to a very high level in a few days. Only a single patient remained negative in the first 5 days from admission, after which he was no more tested. Six patients were followed up for at least two months, and they all showed a decline in IFAT titre, tending to seroreversion (confirmed in one patient with the longest follow up, almost four years). ConclusionsSerology demonstrated reliable for retrospective diagnosis in non immune travellers. The decline in the antimalarial titre might be included in the screening algorithms of blood donors, but further studies are needed.

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Dynamics of antimalarial antibodies in non-immune patients during and after a first and unique P. falciparum malaria episode.

10.21203/rs.2.24522/v2 ◽

2020 ◽

Author(s):

Zeno Bisoffi ◽

Marco Bertoldi ◽

Ronaldo Silva ◽

Giulia Bertoli ◽

Tamara Ursini ◽

...

Keyword(s):

Blood Donors ◽

Travel Medicine ◽

Antibody Test ◽

Malaria Episode ◽

Full Blood Count ◽

Case Report Form ◽

Retrospective Diagnosis ◽

Laboratory Test Results ◽

High Level

Abstract Background Malaria is a major travel medicine issue. Retrospective confirmation of a malaria episode diagnosed in an endemic area can have relevant implications in trasfusional medicine in Europe, where blood donors are excluded from donation on the basis of positive malaria serology. However, there is scarce evidence on the dynamics of antimalarial antibodies after a first malaria episode in non immune individuals. First aim of this study was to describe the dynamics of antimalarial antibodies in a first malaria episode in non immune travellers. Secondary objectives were to assess the sensitivity of serology for a retrospective diagnosis in non immune travellers diagnosed while abroad and to discuss the implications in transfusional medicine. Methods Retrospective analysis of the results of an indirect fluorescence antibody test (IFAT) for malaria available for patients with a first malaria episode by Plasmodium falciparum and admitted at the IRCCS Sacro Cuore Don Calabria hospital in a 14-year period. The antibody titres were collected at baseline and during further follow up visits. Epidemiological, demographic and laboratory test results (including full blood count and malaria parasite density) were anonymously recorded in a study specific electronic Case Report Form created with OpenClinica software. Statistical analysis was performed with SAS software version 9.4. Results Thirty-six patients were included. Among them, all but two were Europeans (one African and one American). Median length of fever before diagnosis was two days (IQR 1-3). Thirty-five patients had seroconversion between day 1 and day 4 from admission, and the titre showed a sharply rising titre, often to a very high level in a few days. Only a single patient remained negative in the first 5 days from admission, after which he was no more tested. Six patients were followed up for at least two months, and they all showed a decline in IFAT titre, tending to seroreversion (confirmed in one patient with the longest follow up, almost four years). Conclusions Serology demonstrated reliable for retrospective diagnosis in non immune travellers. The decline in the antimalarial titre might be included in the screening algorithms of blood donors, but further studies are needed.

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Autoimmune Pancreatitis – Diagnosis, Management and Longterm Follow-up

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld.2014.1121.232.sc1 ◽

2014 ◽

Vol 23 (2) ◽

pp. 179-185 ◽

Cited By ~ 7

Author(s):

Suvadip Chatterjee ◽

Kofi W. Oppong ◽

John S. Scott ◽

Dave E. Jones ◽

Richard M. Charnley ◽

...

Keyword(s):

Autoimmune Pancreatitis ◽

Rare Condition ◽

Team Approach ◽

Diagnostic Challenge ◽

Multisystem Disorder ◽

North East ◽

The North ◽

Work Up ◽

Igg4 Level

Background & Aims: Autoimmune pancreatitis (AIP) is a fibroinflammatory condition affecting the pancreas and could present as a multisystem disorder. Diagnosis and management can pose a diagnostic challenge in certain groups of patients. We report our experience of managing this condition in a tertiary pancreaticobiliary centre in the North East of England.Methods: Patients were identified from a prospectively maintained database of patients diagnosed with AIP between 2005 and 2013. Diagnosis of definite/probable AIP was based on the revised HISORt criteria. When indicated, patients were treated with steroids and relapses were treated with azathioprine. All patients have been followed up to date.Results: Twenty-two patients were diagnosed with AIP during this period. All patients had pancreatic protocol CT performed while some patients had either MR or EUS as part of the work up. Fourteen out of 22 (64%) had an elevated IgG4 level (mean: 10.9 g/L; range 3.4 - 31 g/L). Four (18%) patients underwent surgery. Extrapancreatic involvement was seen in 15 (68%) patients, with biliary involvement being the commonest. Nineteen (86%) were treated with steroids and five (23%) required further immunosuppression for treatment of relapses. The mean follow up period was 36.94 months (range 7 - 94).Conclusion: Autoimmune pancreatitis is being increasingly recognized in the British population. Extrapancreatic involvement, particularly extrahepatic biliary involvement seems to be a frequent feature.Diagnosis should be based on accepted criteria as this significantly reduces the chances of overlooking malignancy. Awareness of this relatively rare condition and a multi-disciplinary team approach will help us to diagnose and treat this condition more efiectively thereby reducing unnecessary interventions.

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Low dose oral ketamine treatment in chronic suicidality: An open-label pilot study

Translational Psychiatry ◽

10.1038/s41398-021-01230-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Adem T. Can ◽

Daniel F. Hermens ◽

Megan Dutton ◽

Cyrana C. Gallay ◽

Emma Jensen ◽

...

Keyword(s):

Suicidal Ideation ◽

Low Dose ◽

Suicide Ideation ◽

Well Being ◽

Primary Outcome Measure ◽

Open Label ◽

Oral Ketamine ◽

High Level ◽

Chronic Suicidality

AbstractRecently, low-dose ketamine has been proposed as a rapid-acting treatment option for suicidality. The majority of studies to date have utilised intravenous (IV) ketamine, however, this route of administration has limitations. On the other hand, oral ketamine can be administered in a range of settings, which is important in treating suicidality, although studies as to safety and feasibility are lacking. n = 32 adults (aged 22–72 years; 53% female) with chronic suicidal thoughts participated in the Oral Ketamine Trial on Suicidality (OKTOS), an open-label trial of sub-anaesthetic doses of oral ketamine over 6 weeks. Participants commenced with 0.5 mg/kg of ketamine, which was titrated to a maximum 3.0 mg/kg. Follow-up assessments occurred at 4 weeks after the final dose. The primary outcome measure was the Beck Scale for Suicide Ideation (BSS) and secondary measures included scales for suicidality and depressive symptoms, and measures of functioning and well-being. Mean BSS scores significantly reduced from a high level of suicidal ideation at the pre-ketamine (week 0) timepoint to below the clinical threshold at the post-ketamine (week 6) timepoint. The proportion of participants that achieved clinical improvement within the first 6 weeks was 69%, whereas 50% achieved a significant improvement by the follow-up (week 10) timepoint. Six weeks of oral ketamine treatment in participants with chronic suicidality led to significant reduction in suicidal ideation. The response observed in this study is consistent with IV ketamine trials, suggesting that oral administration is a feasible and tolerable alternative treatment for chronic suicidality.

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Lower perception of pharmacological treatment increases risk of non-adherence to medication

European Journal of Preventive Cardiology ◽

10.1093/eurjpc/zwab061.258 ◽

2021 ◽

Vol 28 (Supplement_1) ◽

Author(s):

CB Graversen ◽

JB Valentin ◽

ML Larsen ◽

S Riahi ◽

T Holmberg ◽

...

Keyword(s):

Pharmacological Treatment ◽

Poisson Regression ◽

Drug Class ◽

Angiotensin Receptor Blockers ◽

Adverse Outcomes ◽

Adherence To Medication ◽

Increased Risk ◽

Patient Reported ◽

High Level

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Background A large proportion of patients fail to reach optimal adherence to medication following incident ischemic heart disease (IHD) despite amble evidence of the beneficial effect of medication. Non-adherence to medication increases risk of disease-related adverse outcomes but none has explored how perception about pharmacological treatment detail on non-adherence using register-based follow-up data. Purpose To investigate the association between patients’ perception of pharmacological treatment and risk of non-initiation and non-adherence to medication in a population with incident IHD. Methods This cohort study followed 871 patients until 365 days after incident IHD. The study combined patient-reported survey data on perception about pharmacological treatment (categorised by ‘To a high level’, ‘To some level’, and ‘To a lesser level’) with register-based data on reimbursed prescription of cardiovascular medication (antithrombotics, statins, ACE-inhibitors/angiotensin receptor blockers, and β-blockers). Non-initiation was defined as no pick-up of medication in the first 180 days following incident IHD and analysed by Poisson regression. Two different measures evaluated non-adherence in patients initiating treatment: 1) proportion of days covered (PDC) analysed by Poisson regression, and 2) risk of discontinuation analysed by Cox proportional hazard regression. All analyses were adjusted for confounding variables (age, sex, ethnicity, income, educational level, civil status, occupation, charlson comorbidity index, supportive relatives, and individual consultation in medication) identified by directed acyclic graph and obtained from national registers and the survey. Item non-response was handled by multiple imputation and item consistency was evaluated by McDonalds omega. Results Lower perceptions about pharmacological treatment was associated with increased risk of non-initiation and non-adherence to medication irrespectively of drug class and adherence measure in the multiple adjusted analyses (please see figure illustrating results on antithrombotics). A dose-response relationship was observed both at 180- and 365-days of follow-up, but the steepest decline in adherence differed when comparing the two adherence measures (results not shown). Moderate internal consistency was found for the summed measure of perception (McDonalds omega = 0.67). Conclusion Lower perception of pharmacological treatment was associated with subsequent non-initiation and non-adherence to medication, irrespectively of measurement method and drug class. Abstract Figure. Figre: Multiple adjusted analyses

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Decrease post-transplant relapse using donor-derived expanded NK-cells

Leukemia ◽

10.1038/s41375-021-01349-4 ◽

2021 ◽

Author(s):

Stefan O. Ciurea ◽

Piyanuch Kongtim ◽

Doris Soebbing ◽

Prashant Trikha ◽

Gregory Behbehani ◽

...

Keyword(s):

Nk Cells ◽

Nk Cell ◽

Ex Vivo ◽

Disease Free Survival ◽

Dependent Manner ◽

Post Transplant ◽

Haploidentical Transplantation ◽

High Doses ◽

High Level

AbstractIn this phase I/II clinical trial, we investigated the safety and efficacy of high doses of mb-IL21 ex vivo expanded donor-derived NK cells to decrease relapse in 25 patients with myeloid malignancies receiving haploidentical stem-cell transplantation (HSCT). Three doses of donor NK cells (1 × 105–1 × 108 cells/kg/dose) were administered on days −2, +7, and +28. Results were compared with an independent contemporaneously treated case-matched cohort of 160 patients from the CIBMTR database.After a median follow-up of 24 months, the 2-year relapse rate was 4% vs. 38% (p = 0.014), and disease-free survival (DFS) was 66% vs. 44% (p = 0.1) in the cases and controls, respectively. Only one relapse occurred in the study group, in a patient with the high level of donor-specific anti-HLA antibodies (DSA) presented before transplantation. The 2-year relapse and DFS in patients without DSA was 0% vs. 40% and 72% vs. 44%, respectively with HR for DFS in controls of 2.64 (p = 0.029). NK cells in recipient blood were increased at day +30 in a dose-dependent manner compared with historical controls, and had a proliferating, mature, highly cytotoxic, NKG2C+/KIR+ phenotype.Administration of donor-derived expanded NK cells after haploidentical transplantation was safe, associated with NK cell-dominant immune reconstitution early post-transplant, preserved T-cell reconstitution, and improved relapse and DFS. TRIAL REGISTRATION: NCT01904136 (https://clinicaltrials.gov/ct2/show/NCT01904136).

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Ovarian Dysgerminoma in Pregnant Women with Viable Fetus: A Rare Case Report

Case Reports in Oncology ◽

10.1159/000513622 ◽

2021 ◽

pp. 141-146

Author(s):

Reda Youssef ◽

Gamal Sayed Ahmed ◽

Samir Alhyassat ◽

Sanaa Badr ◽

Ahmed Sabry ◽

...

Keyword(s):

Gestational Age ◽

Ovarian Neoplasms ◽

Imaging Modality ◽

Reproductive Age ◽

Diagnostic Challenge ◽

Short Period ◽

Ovarian Dysgerminoma ◽

The Impact ◽

In Pregnancy

Dysgerminoma is an uncommon malignant tumor arising from the germ cells of the ovary. Its association with pregnancy is extremely rare, with a reported incidence of about 0.2–1 per 100,000 pregnancies. Women in the reproductive age group are more commonly affected. It can be extremely rare to conceive naturally, without assisted reproductive interventions, in cases with ovarian dysgerminoma. If a pregnancy does occur with a concurrent dysgerminoma, it is even more unusual to carry the pregnancy to viability or childbirth without fetal or maternal compromise. We report a case of right ovarian dysgerminoma in a young female with a viable intrauterine pregnancy at 10 weeks, which is rarely diagnosed and managed at this gestational age. Numerous factors played a role in her favorable outcome, including early suspicion by ultrasound and presenting history, surgery, histopathological assessment, imaging, and involvement of the multidisciplinary oncology team. Ovarian neoplasms may rapidly increase in size within a short period with little or no symptoms. This poses a diagnostic challenge for obstetricians and oncologists. Hence, we aimed to evaluate the role of imaging in pregnancy using ultrasound as an imaging modality for both early detection of ovarian neoplasms and for follow-up. In conclusion, patients with ovarian dysgerminoma in pregnancy can have favorable outcomes. Treatment should be individualized on a case-to-case basis, depending on many factors; cancer stage, previous reproductive history, the impact of imaging in staging or follow-up of tumor on the fetus, fetal gestational age, and whether termination of the pregnancy can improve survival or morbidity for the mother.

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Prediction of parental alienation on depression in left-behind children: A 12-month follow-up investigation

Epidemiology and Psychiatric Sciences ◽

10.1017/s2045796021000329 ◽

2021 ◽

Vol 30 ◽

Author(s):

Xiaoxiao Sun ◽

Xuemei Qin ◽

Mengjia Zhang ◽

Aigang Yang ◽

Xiaomei Ren ◽

...

Keyword(s):

Life Events ◽

Protective Factor ◽

Stressful Life Events ◽

Parental Alienation ◽

Left Behind ◽

Resilience Scale ◽

Children’S Depression ◽

Risk Predictor ◽

High Level

Abstract Aims Alienation towards parents often occurs when parents divorce; however, it can also occur when one or both parents leave for work for more than 6 months. Our previous investigation has confirmed a high level of feelings of alienation towards parents among Chinese left-behind children. However, the longitudinal prediction of alienation on children's mental health outcomes remains largely unknown. This study aims to observe the prediction of alienation towards parents on children's depression 12 months later and potential mediators and moderators. Methods A total of 1090 Chinese left-behind children took part in this 12-month follow-up investigation, using the Chinese version of the Inventory of Alienation towards Parents (IAP), the Children's Depression Inventory (CDI), the Adolescent Self-Rating Life-events Checklist (ASLEC), and the Adolescent Resilience Scale. Results Alienation towards parents was high (16.42 ± 7.27 for mother, 15.63 ± 7.17 for father) in left-behind children, and 21.01% of children reported depression. Alienation towards parents predicted current depression of children directly and later depression indirectly; children's alienation toward their mothers was a stronger predictor of depression than alienation towards fathers. In models, stressful life-events acted as a risk mediator. Previous depression was the strongest risk predictor, resilience was the strongest protective factor, and duration of fathers’ absence and parents’ marital status moderated the predictive effects. Conclusions This study is among the first to longitudinally confirm that alienation towards parents is a predictor of children's later depression. The results provide important suggestions for families and schools; i.e. to prevent depression in left-behind children, parent−child bonds especially alienation towards mothers, should be carefully considered, and individuals with more negative life-events and weaker resilience need further attention.

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Physical workload and increased frequency of musculoskeletal pain: a cohort study of employed men and women with baseline occasional pain

Occupational and Environmental Medicine ◽

10.1136/oemed-2020-107094 ◽

2021 ◽

pp. oemed-2020-107094

Author(s):

Kathryn Badarin ◽

Tomas Hemmingsson ◽

Lena Hillert ◽

Katarina Kjellberg

Keyword(s):

Survey Data ◽

Musculoskeletal Pain ◽

Leisure Time Physical Activity ◽

Physical Workload ◽

Job Exposure Matrix ◽

Men And Women ◽

Strenuous Work ◽

High Level

ObjectivesMusculoskeletal pain (MSP) is prevalent among the workforce. This study investigates the long-term association between physical workload (PWL) and increased frequency of MSP among male and female employees with pre-existing occasional MSP.MethodsThis study uses the Stockholm Public Health cohort survey data from the baseline 2006. The sample includes 5715 employees with baseline occasional MSP (no more than a few days per month). Eight PWL exposures and overall PWL were estimated using a job-exposure matrix (JEM). The JEM was assigned to occupational titles from a national register in 2006. Follow-up survey data on frequent MSP (a few or more times a week) were collected from 2010. Logistic regressions produced sex-specific ORs with 95% CIs and were adjusted for education, health conditions, psychological distress, smoking, BMI, leisure-time physical activity and decision authority.ResultsAssociations were observed between several aspects of heavy PWL and frequent MSP for men (eg, OR 1.57, 95% CI 1.13 to 2.20, among those in the highest exposure quartile compared with those in the lowest quartile for heavy lifting) and women (eg, OR 1.76, 95% CI 1.35 to 2.29, among those in the highest exposure quartile compared with those in the the lowest quartile for physically strenuous work). Small changes were observed in the OR after adjustment, but most of the ORs for PWL exposures among the men were no longer statistically significantly increased.ConclusionA high level of exposure to heavy PWL was associated with increased frequency of MSP 4 years later for men and women with baseline occasional pain.

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The risk of venous thromboembolism and physical activity level, especially high level: a systematic review

Journal of Thrombosis and Thrombolysis ◽

10.1007/s11239-020-02372-5 ◽

2021 ◽

Author(s):

H. Danin-Mankowitz ◽

A. Ugarph-Morawski ◽

F. Braunschweig ◽

P. Wändell

Keyword(s):

Physical Activity ◽

Systematic Review ◽

Venous Thromboembolism ◽

Activity Level ◽

Case Control Studies ◽

The Third ◽

Area Of Interest ◽

High Level ◽

The Relationship

AbstractVenous thromboembolism (VTE) is the third most common cause of cardiovascular disease. Connection between high level of physical activity (PA) and the onset of VTE is unknown. We searched the literature on the possible association between PA level, especially high levels, and the risk of VTE. A systematic review was carried out to identify relevant articles on the relation between PA level and VTE. The initial search was conducted together with the Karolinska Institutet University Library in February 2018, with follow-up searches after that. In total, 4383 records were found and then screened for exclusion of duplicates and articles outside the area of interest. In total, 16 articles with data on 3 or more levels of PA were included. Of these, 12 were cohort and 4 were case-control studies. Totally 13 studies aimed at investigating VTE cases primarily, while three studies had other primary outcomes. Of the 16 studies, five found a U-shaped association between PA level and VTE risk, although non-significant in three of them. Two articles described an association between a more intense physical activity and a higher risk of VTE, which was significant in one. Nine studies found associations between increasing PA levels and a decreasing VTE risk. Available literature provides diverging results as to the association between high levels of PA and the risk of venous thromboembolism, but with several studies showing an association. Further research is warranted to clarify the relationship between high level PA and VTE.

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