Diagnostic Dilemma: Infective Endocarditis in the Setting of an Esophageal Abscess.

Transesophageal echocardiography (TEE) is the preferred imaging modality to diagnose infective endocarditis (IE). However, esophageal disease can preclude performing a TEE. We present such a scenario. A patient with an esophageal abscess, methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, and septic pulmonary emboli with suspicion for IE based on the modified Duke criteria. However, due to the patient's esophageal abscess, TEE could not be performed safely. We present this case to demonstrate a rare scenario in which a patient with an esophageal abscess also had presumed IE.

Metastatic Jejunal Renal Cell Carcinoma Intussusception Presenting as Melena.

Renal cell carcinoma (RCC) most commonly metastasizes to the lungs, and it is uncommon for RCC to metastasize to the small bowel. Small bowel metastasis commonly presents with gastrointestinal (GI) bleeding. In rare cases, a metastatic small bowel mass can serve as a lead point for intussusception. In this report, we present the case of a male patient whose chief complaint was melena. The patient denied any abdominal pain or nausea. Investigation with push enteroscopy revealed a jejunal mass, and further evaluation with CT showed small bowel intussusception. The patient subsequently underwent small bowel resection and anastomosis. Histopathology confirmed that the jejunal mass was metastatic RCC. We present this case in order to showcase the utility of push enteroscopy in the diagnosis of small bowel metastasis in RCC.

Clostridioides difficile Infection in Patients with Chronic Kidney Disease: A Systematic Review.

Clostridioides difficile infection (CDI) is a health issue of utmost significance in Europe and North America, due to its high prevalence, morbidity, and mortality rate. The clinical spectrum of CDI is broad, ranging from asymptomatic to deadly fulminant colitis. When associated with chronic kidney disease (CKD), CDI is more prevalent and more severe than in the general population, due to specific risk factors such as impaired immune system, intestinal dysmotility, high antibiotic use leading to disturbed microbiota, frequent hospitalization, and PPI use. We performed a systematic review on the issue of prevention and treatment of CDI in the CKD population, analysing the suitable randomized controlled cohort studies published between 2000 and 2021. The results show that the most important aspect of prevention is isolation and disinfection with chlorine-based solution and hydrogen peroxide vapour to stop the spread of bacteria. In terms of prevention, using Lactobacillus plantarum (LP299v) proved to be more efficient than disinfection measures in transplant patients, leading to higher cure rates and less recurrent episodes of CDI. Treatment with oral fidaxomycin is more effective than with oral vancomycin for the initial episode of CDI in CKD patients. Faecal microbiota transplantation (FMT) is more effective than vancomycin in recurrent CDI in CKD patients. More large-sample RCTs are necessary to conclude on the best treatment and prevention strategy of CDI in CKD patients.

Nutritional status improvement in elderly CKD patients: a systematic review.

PURPOSE: Almost all CKD patients have a poor nutritional status, while elderly CKD patients are specifically frail and malnourished. Our aim is to conduct a systematic review of the up to date primary studies that look at methods of improving nutritional status in CKD patients in the elderly demographic. METHODS: A focussed and sensitive search strategy was applied to the PUBMED database to identify relevant English language articles. Once articles were identified a detailed quality and bias assessment was performed. Two independent researchers (MZ and SM) then subsequently carried out detailed data extraction and analysis and this was subsequently verified by a third researcher (IN). RESULTS: A total of 19 studies were included in our systematic review which included 7 non-randomised control trials and 15 randomised controlled trials. The outcomes that we considered to be most relevant for our subject title were: mortality data, SGA, albumin, total protein, isoleucine, leucine, prealbumin, transferrin, leptin, valine, TAG, HDL, LDL and total amino acids. Detailed bias analysis of the different studies was also conducted. CONCLUSION: This is the first systematic review of the literature, so far, on the subject, involving elderly CKD patients. The quality of trials is low, very heterogenic in patients, methods and outcomes. However, we found a positive effect of dietary interventions on the nutritional status of most patients studied, highlighted by improvement in serum albumin and SGA, the most measured outcomes.

Acral lentiginous melanoma: A retrospective study.

BACKGROUND: Acral lentiginous melanoma (ALM) carries one of the worst prognoses among other subtypes. This malignant tumor is found on the distal limbs and is usually detected at late stages. Hereby, the authors present their experience on this melanoma subtype. METHODS: A retrospective study was conducted. Data were extracted from patients' medical records and from phone interviews. RESULTS: A total of 43 patients were included in the study. The main signs and symptoms disclosed by the patients were bleeding (41.9%), size greater than 6 mm (41.9%), change in size (37.2%), change in shape (30.2%), rise above the surface of the skin (27.9%), change in color (20.9%), irregular borders (16.3%), and inflammation (16.3%). The first healthcare professional consulted was a general practitioner or a dermatologist in the majority of cases (88.3%). Only 44.2% of the patients were sent by their first physician for a biopsy, whereas 30.3% were sent by the 2nd physician. 14 patients underwent biopsy within 1 month from the first appointment with a physician, while 20 patients within 3 months and 9 patients within 6 months. Only 7 patients sought medical attention in the first 3 months; 21 patients sought medical care between 3 months and one year from the appearance of the lesion, while the remaining 15 patients waited more than a year. CONCLUSIONS: One of the major issues found in ALM is represented by the diagnostic delay; this may be due to either the patients or the physicians' failure to recognize warning signs.