Impact of immune checkpoint molecules on FoxP3+ Treg cells and related cytokines in patients with acute and chronic brucellosis

Background The immunoregulatory functions of regulatory T cells (Tregs) in the development and progression of some chronic infectious diseases are mediated by immune checkpoint molecules and immunosuppressive cytokines. However, little is known about the immunosuppressive functions of Tregs in human brucellosis, which is a major burden in low-income countries. In this study, expressions of immune checkpoint molecules and Treg-related cytokines in patients with acute and chronic Brucella infection were evaluated to explore their impact at different stages of infection. Methods Forty patients with acute brucellosis and 19 patients with chronic brucellosis admitted to the Third People’s Hospital of Linfen in Shanxi Province between August 2016 and November 2017 were enrolled. Serum and peripheral blood mononuclear cells were isolated from patients before antibiotic treatment and from 30 healthy subjects. The frequency of Tregs (CD4+ CD25+ FoxP3+ T cells) and expression of CTLA-4, GITR, and PD-1 on Treg cells were detected by flow cytometry. Levels of Treg-related cytokines, including IL-35, TGF-β1, and IL-10, were measured by customised multiplex cytokine assays using the Luminex platform. Results The frequency of Tregs was higher in chronic patients than in healthy controls (P = 0.026) and acute patients (P = 0.042); The frequency of CTLA-4+ Tregs in chronic patients was significantly higher than that in healthy controls (P = 0.011). The frequencies of GITR+ and PD-1+ Tregs were significantly higher in acute and chronic patients than in healthy controls (P < 0.05), with no significant difference between the acute and chronic groups (all P > 0.05). Serum TGF-β1 levels were higher in chronic patients (P = 0.029) and serum IL-10 levels were higher in acute patients (P = 0.033) than in healthy controls. We detected weak correlations between serum TGF-β1 levels and the frequencies of Tregs (R = 0.309, P = 0.031) and CTLA-4+ Tregs (R = 0.302, P = 0.035). Conclusions Treg cell immunity is involved in the chronicity of Brucella infection and indicates the implication of Tregs in the prognosis of brucellosis. CTLA-4 and TGF-β1 may contribute to Tregs-mediated immunosuppression in the chronic infection stage of a Brucella infection.

Coping Strategies and Stress Related Disorders in Patients with COVID-19

Patients with severe COVID-19 experience high-stress levels and thus are at risk for developing acute stress disorder (ASD) and/or post-traumatic stress disorder (PTSD). The present study aims to search for correlations between psychiatric response to stress and coping strategies among individuals with acute vs. remitted COVID-19. Ninety subjects with COVID-19 were included in the study, divided into two samples by disease category. Our focus was analysing the perceived stress intensity according to NSESSS and PCL-C-17 scales, and coping strategies with COPE-60. High NSESSS scores were found in 40% of acute patients, and 15.6% of remitted patients had high PCL-C-17 scores fulfilling the criteria for PTSD. We found a negative correlation between stress level and disease category. Acute patients used significantly more engagement and emotion-focused coping methods, but less disengagement types of coping than patients in the remitted phase. Remitted patients under high stress levels are prone to use disengagement and emotion-focused coping strategies. In conclusion, remitted COVID-19 patients experience lower levels of stress and use less emotion-focused strategies, except among those who developed PTSD post-COVID-19 infection, presenting with high-stress levels and using more disengagement and emotion-focused types of coping strategies.

Differentiation in Neurological Soft Sign Scores on Schizophrenic Patients with Antipsychotic Treatment

Background: Schizophrenia is a chronic mental illness that affects cognitive aspect of a patient which need long term care with antipsychotics. Long term use of antipsychotic itself causes neurobiological change in the brain which results in alteration of cognitive function. The latest research had demonstrated that NSS (Neurological Soft Sign) reflect a rather wide range of cognitive impairments in schizophrenia which was not accounted for by age, education or severity of global cognitive deficits. Therefore, we examined the effects and impact of antipsychotic Haloperidol and Risperidone treatment in schizophrenic patient using NSS scores. The Study showed that chronic schizophrenia patients had a higher NSS scores than acute patients. NSS also significantly associated with all neuropsychological domains of MMSE in both groups and were confirmed when age, education and severity of global cognitive deficits were not accounted for. This study also obtained a lower NSS score in patients who received Risperidone therapy compared to Haloperidol with p = 0.003. Out of 5 NSS domain in the Heidelberg scale, there was a significant improvement in motor coordination and motor sequencing (p = 0.004) and (p = 0.048) in patients who received Risperidone therapy compared to Haloperidol. There was an association between the chronicity of the disease and NSS, NSS also shows that it’s not influenced by age, education and severity of global cognitive deficits as a screening instrument. Finally the improvement of NSS scores in the Risperidone group was far superior compared to the Haloperidol group particularly in motor coordination and motor sequencing.

Acute or chronic periprosthetic joint infection? Using the ESR ∕ CRP ratio to aid in determining the acuity of periprosthetic joint infections

Introduction: The gold standard for determining the duration of periprosthetic joint infection (PJI) is a thorough history. Currently, there are no well-defined objective criteria to determine the duration of PJI, and little evidence exists regarding the ratio between ESR (mm/h) and CRP (mg/L) in joint arthroplasty. This study suggests the ESR / CRP ratio will help differentiate acute from chronic PJI. Methods: Retrospective review of patients with PJI was performed. Inclusion criteria: patients >18 years old who underwent surgical revision for PJI and had documented ESR and CRP values. Subjects were divided into two groups: PJI for greater (chronic) or less than (acute) 4 weeks and the ESR / CRP ratio was compared between them. Receiver-operating characteristic (ROC) curves were evaluated to determine the utility of the ESR / CRP ratio in characterizing the duration of PJI. Results: 147 patients were included in the study (81 acute and 66 chronic). The mean ESR / CRP ratio in acute patients was 0.48 compared to 2.87 in chronic patients (p<0.001). The ESR / CRP ROC curve demonstrated an excellent area under the curve (AUC) of 0.899. The ideal cutoff value was 0.96 for ESR / CRP to predict a chronic (>0.96) vs. acute (<0.96) PJI. The sensitivity at this value was 0.74 (95 % CI 0.62–0.83) and the specificity was 0.90 (95 % CI 0.81–0.94). Conclusions: The ESR / CRP ratio may help determine the duration of PJI in uncertain cases. This metric may give arthroplasty surgeons more confidence in defining the duration of the PJI and therefore aid in treatment selection.

267 Ascertain Impact of Using Low-Fidelity Simulation Scenarios in Preparation for Practical Surgical Finals

Introduction Simulation has become the new way of preparing doctors to deal with medical emergencies, we investigate it using in managing ward-based surgical emergencies. Method Final year medical students completed pre- and post-session questionnaires related to themes of preparedness, anxiousness, and confidence in management of acute surgical presentations versus post-operative complications. The intervention was divided into classroom based teaching and common surgical scenarios enacted using Sim-Man. Results Preparedness increased by a third following participation in surgical simulation scenarios among participants. Anxiousness related to surgical finals decreased by 9%. Confidence in managing acute patients increased by 25% compared to pre-session results. Moreover, 35% of participants felt more confident in managing post-operative complications after the session. On average, participants scored 8/10 for usefulness of the sessions in highlighting areas to concentrate focus upon during revision. Conclusions Simulation is slowly becoming a staple in undergraduate training and our results emphasise positive impact of using this as a revision tool. Kinaesthetic learning is more memorable during simulation which serves as a confidence boost in self-perception of managing both acute and post-operative surgical patients. Anxiety associated with exams and managing real-life emergencies can be dampened by rehearsing scenarios and following a structured approach as championed by medical simulation.

Influence of Locomotion Therapy With the Wearable Cyborg HAL on Bladder and Bowel Function in Acute and Chronic SCI Patients

Study Design: Retrospective survey. Objectives: Purpose of this study was to explore whether bowel and bladder management can be influenced by locomotion therapy with HAL Robot Suit. Methods: 35 subjects with acute (< one year since injury, n = 13) or chronic (> one year since injury, n = 22) incomplete paraplegia (American Spinal Injury Association Impairment Scale (AIS) B, n = 1 / AIS C, n = 22 / AIS D, n = 7) or complete paraplegia (AIS A, n = 5) with zones of partial preservation (ZPP) participated. A retrospective survey was carried out asking for bowel incontinence (Wexner Score), constipation (Cleveland Clinic Constipation Scoring System (CCCS)) and bladder function (self-developed questionnaire) before and after completing a training period of 12 weeks with HAL. Results: Wexner Score over all patients and for group of chronic patients decreased significantly. For group of acute patients Wexner Score decreased insignificantly. Patients from both groups with higher baseline scores could decrease significantly. CCCS was insignificantly reduced for all patients, group of acute and group of chronic patients. For subgroup of chronic patients with higher baseline scores, CCCS decreased at end of training period missing out significance. The self-developed questionnaire showed an improvement in bladder function in 28.24% of all patients, 31.43% of chronic patients, and 23.08% of acute patients. Conclusions: Our findings show trends of enhanced bladder and bowel function following exoskeleton training. Patients with higher baseline scores in Wexner Score and CCCS seem to benefit more than those with mild to moderate scores.

Differential gene expression of ABCG2, SLC22A12, IL-1β and ALPK1 in peripheral blood leukocytes of primary gout patients, was associated to hiperuricemia and their comorbidities. A case control study

Background. Genes ABCG2, SLC22A12, and ALPK1 have been strongly associated with dysfunction of urate metabolism in patients with gout, but it is unknown how these transporters are expressed in patients with acute or chronic gout. Our objective was to analyze the gene expression of urate transporters and inflammation genes in peripherial blood from gout patients and controls, to determinate if the metabolic profile of gout patients can influence at the gene expression profile. Our objective was to analyze the expression of urate transporters ABCG2, SLC22A12 and inflammation molecules ALPK1 and IL-1β in peripheral blood leukocytes from gout patients and to compare them with their metabolic profile and with the gene expression of people without gout and without hyperuricemia.Methods. A total of 36 chronic and acute patients and 52 controls were recruited, ABCG2, SLC22A12, IL-1β and ALPK1 gene expression was evaluated by quantitative real-time PCR. Correlations of gene expression with clinical and laboratory parameters of patients were also analyzed.Results. IL-1β was significantly increased in PBMCs of patients when compared with their PMNLs (p<0.05). A significant increase in ABCG2 and IL-1β were found in PMNLs from patients compared to controls (p<0.05). Correlations of gene expression in patients were related to levels of serum uric acid (sUA), serum creatinine, CRP, triglycerides, BMI, kidney disease, hypertension, and metabolic syndrome.Conclusions. Our data suggest that the leukocyte cells of the patients respond to the presence hyperuricemia and comorbidities expressing ABCG2 and IL-1β genes differentially compared to normouricemic and non disease state. Hyperuricemia, dyslipidemias and obesity should stimulate the differential gene expression of peripheral blood leukocytes (neutrophils and monocytes) even in an asymptomatic state.

Point of Care Ultrasound during the Medical Teaching Rounds in the COVID-19 Era -The Hospitalist Perspective-

In Internal Medicine, POCUS is gaining significant favorability. An increasing number of clinicians are interested in being trained for POCUS. The newer portable ultrasounds are small and can be transported easily during rounds. Their design is now for a more intuitive use. Training of Internists now involves assessing patients utilizing POCUS technology in residency. Here at Danbury Hospital, we have formal POCUS training. Attending internists are now attempting to incorporate POCUS training as a part of continuing medical education. POCUS in the hospitalist or general practitioner world has not been completely defined. Generally, the patient seen in the medical ward is not ill as the patients seen in intensive care units (ICU), Emergency Department (ED), and other high acute-care settings. However, from time to time, internists need to treat high acuity patients on the medical floors before transferring them to a higher level of care or when they are required to cover an open ICU or Progressive Care Unit (step-down unit). The role of POCUS while managing stable patients may differ significantly compared to the role in more acute patients. A well-defined spectrum for the use of POCUS does not currently exist. However, there are efforts in this regard. POCUS is an emerging and exciting diagnostic modality in the medical ward. We believe that the pandemic has given it a new meaning for the hospitalist and general practitioner, and we expect that its use and significance will only grow in the few years ahead.