Fever of unknown origin: discrimination between infectious and non-infectious causes.

OBJECTIVE: The present study aimed to develop and evaluate a simple diagnostic model that could aid physicians to discriminate between infectious and non-infectious causes of fever of unknown origin (FUO). DESIGN/SETTING/SUBJECTS: Patients with classical FUO were studied in two distinct, prospective, observational phases. In the derivation phase that lasted from 1992 to 2000, 33 variables regarding demographic characteristics, history, symptoms, signs, and laboratory profile were recorded and considered in a logistic regression analysis using the diagnosis of infection as a dependent variable. In the validation phase, the discriminatory capacity of a score based on the derived predictors of infection was calculated for FUO patients assessed from 2001 to 2007. RESULTS: Data from 112 individuals (mean age 56.5+/-11.2 years) were analyzed in the derivation cohort. The final diagnoses included infections, malignancies, non-infectious inflammatory diseases, and miscellaneous conditions in 30.4%, 10.7%, 33% and 5.4% of subjects, whereas 20.5% of cases remained undiagnosed. C-reactive protein>60 mg/L (odds ratio 6.0 [95% confidence intervals 2.5, 9.8]), eosinophils<40/mm(3) (4.1 [2.0, 7.3]) and ferritin<500 microg/L (2.5 [1.3, 5.2]) were independently associated with diagnosis of infection. Among the 100 patients of the validation cohort, the presence of > or =2 of the above factors predicted infection with sensitivity, specificity, and positive and negative predictive values of 91.4%, 92.3%, 86.5%, and 95.2%, respectively. CONCLUSIONS: The combination of C-reactive protein, ferritin and eosinophil count may be useful in discriminating infectious from non-infectious causes in patients hospitalised for classical FUO.

Smoking cessation increases serum adiponectin levels in an apparently healthy Greek population.

BACKGROUND: Smoking has been associated with low serum levels of adiponectin, an adipocytokine with insulin-sensitizing, anti-inflammatory and anti-atherogenic properties. The objective of this study was to assess the early effect on adiponectin levels of smoking cessation supported by bupropion. METHODS: Apparently healthy smokers of both sexes with no additional cardiovascular risk factors were administered 150mg sustained-release bupropion twice daily for 9 weeks. Quitters constituted the active group and non-quitters the control group. Sandwich enzyme-linked immunosorbent assays were employed for the measurement of serum adiponectin and cotinine, the latter used for validation of self-reported abstinence. RESULTS: Among the 106 participants (mean age 44.5+/-11.3 years, 57 females, Brinkman index 512.2+/-98.4, basal adiponectin 7.2+/-1.5mg/L), 45 (42.5%) had quitted smoking at week 9. Quitters' post-cessation adiponectin levels were significantly increased (mean difference with baseline 1.9+/-0.8mg/L, 95% CI 1.2, 2.3; p<0.001), while non-quitters' adiponectin remained unaltered. A multiple regression model including female gender (standardized beta coefficient=0.480, p=0.002), age (0.355, p=0.003), body mass index (BMI) (-0.308, p=0.005), waist circumference (-0.276, p=0.008), smoking status (-0.255, p=0.010), and cotinine levels (-0.233, p=0.021) explained about two thirds of the variation in adiponectin levels (adjusted R(2)=0.656). CONCLUSIONS: Serum adiponectin levels appear to increase considerably within 2 months after smoking cessation. This finding may provide further insight into the mechanisms related to the detrimental effects of smoking and the benefits of quitting.

Blood pressure and risk of renal cell carcinoma in the European prospective investigation into cancer and nutrition.

Elevated blood pressure has been implicated as a risk factor for renal cell carcinoma (RCC), but prospective studies were confined to men and did not consider the effect of antihypertensive medication. The authors examined the relation among blood pressure, antihypertensive medication, and RCC in the European Prospective Investigation into Cancer and Nutrition (EPIC). Blood pressure was measured in 296,638 women and men, recruited in eight European countries during 1992-1998, 254,935 of whom provided information on antihypertensive medication. During a mean follow-up of 6.2 years, 250 cases of RCC were identified. Blood pressure was independently associated with risk of RCC. The relative risks for the highest versus the lowest category of systolic (>/=160 mmHg vs. <120 mmHg) and diastolic (>/=100 mmHg vs. <80 mmHg) blood pressures were 2.48 (95% confidence interval: 1.53, 4.02) and 2.34 (95% confidence interval: 1.54, 3.55). Risk estimates did not significantly differ according to sex or use of antihypertensive medication. Individuals taking antihypertensive drugs were not at a significantly increased risk unless blood pressure was poorly controlled. These results support the hypothesis that hypertension, rather than its medications, increases the risk of RCC in both sexes, while effective blood pressure control may lower the risk.

Prognostic significance of plasma resistin levels in patients with atherothrombotic ischemic stroke.

BACKGROUND: Resistin (RSN) is an adipocytokine involved in insulin resistance, obesity and atherosclerosis. This study aimed to investigate the association between plasma RSN and outcome after ischemic stroke. METHODS: RSN measured within 24 h after the event was related to functional outcome and 5-year survival in 211 subjects with first-ever atherothrombotic ischemic stroke. Prognosis was assessed by the Kaplan Meier and the Cox techniques. RESULTS: The probabilities of death were 80.4%, 46.2% and 15.7% (p<0.001) for patients stratified according to tertiles of RSN (>30 ng/mL, 20-30 ng/mL and<20 ng/mL, respectively). The proportion of dependency (modified Rankin Scale score>or=3) was greater in 5-year survivors with RSN in the upper tertile (6/11 [54.5%]) compared to the middle (20/56 [35.7%]) and the lowest tertile (8/43 [18.6%]; p<0.01). C-reactive protein levels (hazard ratio [HR] 3.96 [95% CI 2.06, 8.91]; p<0.001), coronary heart disease (2.69 [1.62, 6.23]; p<0.001), RSN levels (2.12 [1.31, 5.08] p<0.001), National Institute of Health Stroke Scale score (2.02 [1.23, 4.49]; p<0.01) and age (1.84 [1.19, 3.93]; p<0.01) were independent predictors of death. CONCLUSIONS: High plasma RSN appears to be associated with increased risk of 5-year mortality or disability after atherothrombotic ischemic stroke, independently of other adverse predictors.

Lung mass caused by Phoma exigua.

We describe a well documented case of a fatal Phoma exigua lung infection in a patient with acute myeloid leukaemia and diabetes. The infection was histology and culture proven and a PCR assay was developed for detecting P. exigua DNA in deparaffinized lung-biopsy material. Confirmation of rare fungal pathogen infections requires a multidisciplinary approach involving clinical observations, mycology, histopathology and radiology.

Thymoma with immunodeficiency (Good's syndrome): review of the literature apropos three cases.

Good's syndrome is the association of thymoma with immunodeficiency, characterized by hypogammaglobulinaemia, depleted B-cells, diminished T-cells and inversion of the CD4/CD8 ratio. The initial clinical presentation is either with a mass lesion-thymoma that is usually benign, or with recurrent infections due to immunodeficiency. Thymectomy usually favourably affects associated conditions, such as pure red cell aplasia, but does not improve hypogammaglobulinaemia, thus the patient remains dependent on intravenous immune globulin and prone to infections. Infections usually affect the respiratory and/or the gastrointestinal tract. Common respiratory, opportunistic, and eventually life-threatening infections may occur. Moreover, patients with Good's syndrome may present other haematological conditions. We report 3 cases with long follow-up, sharing some common manifestations of the syndrome, but also showing unique features. The principal features of this rare syndrome are further discussed.

Differentiation between patients with acute upper gastrointestinal bleeding who need early urgent upper gastrointestinal endoscopy and those who do not. A prospective study.

OBJECTIVE: To differentiate, among patients presented at the emergency department with acute upper gastrointestinal bleeding, those who need early urgent upper gastrointestinal endoscopy from those who do not. METHODS: Seventeen variables for each patient presenting with upper gastrointestinal bleeding were prospectively recorded and considered in a multivariate analysis. We used the presence of active bleeding during early urgent upper gastrointestinal endoscopy within 12 h from admission as the end point. The derived score was validated with data from the next consecutive patients presenting with upper gastrointestinal bleeding. RESULTS: Among 190 consecutive patients (mean age 63.7 +/- 16 years; 64.7% men), active bleeding was observed in 51 patients (26.8%). Four variables were identified as independent predictors (P < 0.05) of active bleeding in early urgent upper gastrointestinal endoscopy and were used for the derivation of the following integer-based scoring system: number of points = 6 (fresh blood in nasogastric tube) + 4 (haemodynamic instability) + 4 (haemoglobin < 8 g/dl) + 3 (white blood cell count > 12 000/microl). The validation study consisted of 110 patients (71 men; mean age 66.1 +/- 14 years; 28 patients [25.5%] with active bleeding). In this study, a cut off of < 7 points indicated absence of active bleeding and >/= 11 points indicated presence of active bleeding; this gave a sensitivity of 96%, specificity of 98%, positive predictive value of 96% and negative predictive value of 98%. CONCLUSIONS: Simple clinical and laboratory variables available at presentation can be used to differentiate patients with upper gastrointestinal bleeding who do not need an early urgent upper gastrointestinal endoscopy from those who do.

Effect of estrogen receptor modulator tamoxifen on blood pressure, plasma renin activity, and renal sodium excretion.

BACKGROUND: Adjuvant treatment with the estrogen receptor modulator tamoxifen is a well established long-term therapy in breast cancer. This study investigated the effect of tamoxifen on blood pressure (BP) and on factors by which it might be influenced. METHODS: Normotensive postmenopausal women on > 12 months adjuvant tamoxifen therapy were randomized to withdraw or continue tamoxifen for 6 weeks and then to crossover to the alternative regimen for a second 6-week period. Measurements of clinic and ambulatory BP, plasma renin activity (PRA), and fractional sodium excretion (FE(Na)) were performed at baseline and at the end of each study period. RESULTS: Twenty-three women completed the study (mean age 60.6 +/- 8.3 years). There was no effect of tamoxifen on clinic BP (mean difference between withdrawal and continuation for systolic BP, 0.4 +/- 8.4 mm Hg, 95% confidence interval [CI] -4.0 to 3.2, and diastolic 0.6 +/- 4.7, 95%CI -1.4 to 2.7) or 24-hour ambulatory BP (systolic 0.7 +/- 7.4 mmHg, 95%CI -2.6 to 3.9; diastolic BP, 1.9 +/- 5.5, 95% CI -0.5 to 4.2). Furthermore, no effect of tamoxifen on PRA (mean difference between withdrawal and continuation 0.03 +/- 0.5 ng/mL/h, 95% CI -0.3 to 0.2) or FENa (0.05 +/- 0.5, 95% CI -0.2 to 0.2) was detected. CONCLUSIONS: Tamoxifen seems to have no effect on BP, PRA, or FE(Na) in normotensive postmenopausal women.