Diagnostic Value of Microbial Cell-free DNA Sequencing for Suspected Invasive Fungal Infections: A Retrospective Multicenter Cohort Study.

Background: An early diagnosis and treatment of invasive fungal disease (IFD) is associated with improved outcome, but the moderate sensitivity of noninvasive diagnostic tests makes this challenging. Invasive diagnostic procedures such as bronchoalveolar lavage (BAL) have a higher yield but are not without risk. The detection and sequencing of microbial cell-free DNA (mcfDNA) may facilitate a noninvasive diagnosis. Materials: In a prospective observational study, we collected plasma in the 120 hours preceding or following a BAL in patients with hematological malignancies suspected for a pulmonary IFD. The EORTC/MSGERC2020 criteria were used for IFD classification. Sequencing was performed by Karius (Redwood City, CA) using their Karius Test (KT) on plasma and a "research use only test" on BAL fluid if available. Cases with a probable/proven IFD were identified based on standard diagnostic tests on serum and BAL (microscopy, polymerase chain reaction, galactomannan, culture) and used to calculate the sensitivity, specificity, and additional diagnostic value of the KT. Results: Of 106 patients enrolled, 39 (37%) had a proven/probable invasive aspergillosis, 7 (7%) a non-Aspergillus IFD, and 4 (4%) a mixed IFD. The KT detected fungal mcfDNA in 29 (28%) patients. Compared with usual diagnostic tests, the sensitivity and specificity were 44.0% (95% confidence interval [CI], 31.2-57.7) and 96.6% (95% CI, 88.5%-99.1%). Sensitivity of the KT was higher in non-Aspergillus IFD (Mucorales:2/3, Pneumocystis jirovecii: 3/5). On BAL, the sensitivity was 72.2% (95% CI, 62.1-96.3), and specificity 83.3% (95% CI, 49.1-87.5). Conclusions: Sequencing of mcfDNA may facilitate a noninvasive diagnosis of IFD in particular non-Aspergillus IFD. However, on plasma and similar to currently available diagnostics, it cannot be used as a "rule-out" test.

Iron metabolism is prospectively associated with insulin resistance and glucose intolerance over a 7-year follow-up period: the CODAM study.

OBJECTIVES: Several markers of iron metabolism have been associated with insulin resistance (IR) and type 2 diabetes mellitus in cross-sectional studies. However, prospective data on these associations are scarce, and it is currently unclear in which tissues iron metabolism may contribute to IR. Therefore, we investigated whether markers of iron metabolism were associated with IR in muscle, liver, and adipocytes, and with glucose intolerance over a 7-year follow-up period. DESIGN AND METHODS: Serum ferritin, transferrin, total iron, non-transferrin-bound iron, and transferrin saturation were determined at baseline of a prospective cohort study in 509 individuals (60 % men, age 59 ± 6.9 years, body mass index 28.5 ± 4.3). Both at baseline and after a 7-year follow-up (n = 386), measures of glucose, insulin (during glucose tolerance tests), and non-esterified fatty acids were obtained. Using generalized estimating equations, we investigated associations between baseline iron markers and indices of muscle, liver, and adipocyte insulin resistance (adipocyte IR), as well as glucose intolerance, over the 7-year period. RESULTS: Over a 7-year period, baseline serum ferritin (per 10 µg/L increase) was positively associated with homeostasis model assessment insulin resistance (HOMA2-IR) [ß = 0.77 % (95 % CI 0.50-1.03)], hepatic insulin resistance (hepatic IR) [ß = 0.39 % (0.23-0.55)], adipocyte IR [ß = 1.00 % (0.65-1.35)], and AUCglucose [ß = 0.32 % (0.18-0.46)] after adjustment for several covariates, including inflammatory markers (all p < 0.001). Similarly, serum transferrin (per 0.1 g/L) was associated with HOMA2-IR [ß = 2.66 % (1.55-3.78)], hepatic IR [ß = 1.16 % (0.47-1.85)], adipocyte IR [ß = 3.75 % (2.27-5.25)], and AUCglucose [ß = 1.35 % (0.74-1.96)] over 7 years. CONCLUSIONS: Iron metabolism and related factors may contribute to IR in muscle, liver, and adipocytes, eventually leading to impaired glucose metabolism and hyperglycaemia.

Complement factor 3 is associated with insulin resistance and with incident type 2 diabetes over a 7-year follow-up period: the CODAM Study.

OBJECTIVE: Immune dysregulation can affect insulin resistance (IR) and ß-cell function and hence contribute to development of type 2 diabetes mellitus (T2DM). The complement system, as a regulator of immune and inflammatory homeostasis, may be a relevant contributor therein. However, longitudinal studies focusing on complement as a determinant of T2DM and IR are scarce. Therefore, we prospectively investigated the association of plasma complement factor 3 (C3) with (estimates of) IR in muscle, liver, and adipocytes, as well as with glucose tolerance, including incident T2DM. RESEARCH DESIGN AND METHODS: Fasting C3, nonesterified fatty acids, glucose, and insulin (the latter two during oral glucose tolerance tests) were measured at baseline (n = 545) and after 7 years of follow-up (n = 394) in a prospective cohort study. RESULTS: Over the 7-year period, C3 levels (per 0.1 g/L) were longitudinally associated with higher homeostasis model assessment of IR (HOMA2-IR; ß = 15.2% [95% CI 12.9-17.6]), hepatic IR (ß = 6.1% [95% CI 4.7-7.4]), adipocyte IR (ß = 16.0% [95% CI 13.0-19.1]), fasting glucose (ß = 1.8% [95% CI 1.2-2.4]), 2-h glucose (ß = 5.2% [95% CI 3.7-6.7]), and area under the curve for glucose (ß = 3.6% [95% CI 2.7-4.6]). In addition, greater changes in C3 (per 0.1 g/L) were associated with greater changes in HOMA2-IR (ß = 0.08 [95% CI 0.02-0.15]) and greater changes in hepatic IR (ß = 0.87 [95% CI 0.12-1.61]) over 7 years, but not glucose tolerance. Moreover, baseline C3 was associated with the 7-year incidence of T2DM (odds ratio 1.5 [95% CI 1.1-2.0]). CONCLUSIONS: Changes in C3 were associated with changes in several measures of IR and may reflect progression of metabolic dysregulation, which eventually leads to abnormalities in glucose tolerance and T2DM.

Diabetes mellitus at the time of diagnosis of cirrhosis is associated with higher incidence of spontaneous bacterial peritonitis, but not with increased mortality.

DM (diabetes mellitus) is present in 20-40% of patients with liver cirrhosis, but its prognostic impact is unclear. Therefore, in the present study, we investigated whether the presence of DM in patients with cirrhosis was associated with increased mortality, and/or with increased incidence of SBP (spontaneous bacterial peritonitis). We reviewed medical and laboratory data of 230 patients with cirrhosis from the period 2001-2011, for whom data were complete in n=226. Follow-up for the outcomes mortality and SBP was performed until May 2012, with only 13 patients lost to follow-up. DM was present at baseline in 78 patients (35%). Median follow-up was 6.2 (interquartile range, 3.1-9.3) years, during which 118 patients died [47 out of 78 with DM (60%), and 71 out of 148 without DM (48%)]. The presence of DM at baseline was not associated with increased mortality after adjustment for age {HR (hazard ratio), 1.00 [95% CI (confidence interval), 0.67-1.50]}. Further adjustment for sex, aetiology of cirrhosis, platelet count and the Child-Pugh or MELD (model for end-stage liver disease) score did not change this finding. During follow-up, 37 patients developed incident SBP (19 with DM and 18 without DM). DM at baseline was associated with incident SBP, even after adjustment for age, sex, aetiology, platelet count and the Child-Pugh [HR, 2.39 (95% CI, 1.10-5.18)] or MELD score [HR, 2.50 (95% CI, 1.16-5.40)]. In conclusion, the presence of DM at baseline in patients with cirrhosis was associated with an increased risk of SBP, which may represent an increased susceptibility to infections. On the other hand, DM was not clearly associated with increased mortality in these patients.

Activated complement factor 3 is associated with liver fat and liver enzymes: the CODAM study.

BACKGROUND: The complement system may be involved in the pathogenesis of alcoholic and nonalcoholic liver disease, although studies in humans are scarce. For this reason, we investigated whether circulating levels of activated complement factor 3 (C3a) were associated with hepatic steatosis and hepatocellular damage. MATERIALS AND METHODS: Plasma C3a, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) were determined in 523 individuals (61% men, age 59 ± 7 years). Liver enzymes (LEs) were standardized and compiled into a LE score. Liver fat content was estimated using a predictive equation that has recently been validated with magnetic resonance spectrometry. Cross-sectional associations between C3a and liver fat or LE s were investigated with multiple linear regression analyses, stratified in no-to-moderate vs. heavy alcohol consumers (men: > 30 g/day; women: > 20 g/day). RESULTS: C3a was associated with liver fat percentage both in the no-to-moderate (ß = 0.223; 95%CI 0.036; 0.409) and in the heavy alcohol consumers (ß = 0.632; 95%CI 0.259-1.004; P-interaction = 0.047). C3a was also associated with the LE score in heavy alcohol consumers (ß = 0.917; 95%CI 0.443-1.392), but not in no-to-moderate alcohol consumers (ß = 0.042; 95%CI -0.198 to 0.281; P-interaction = 0.001). CONCLUSIONS: C3a levels, as a marker of complement activation, were associated with liver fat content and hepatocellular injury, at least in subjects who consume considerable amounts of alcohol daily.

Iron metabolism is associated with adipocyte insulin resistance and plasma adiponectin: the Cohort on Diabetes and Atherosclerosis Maastricht (CODAM) study.

OBJECTIVE: Adipocyte insulin resistance (IR) is a key feature early in the pathogenesis of type 2 diabetes mellitus (T2DM), and although scarce, data in the literature suggest a direct role for iron and iron metabolism-related factors in adipose tissue function and metabolism. Serum ferritin and transferrin were shown to be associated with muscle insulin resistance (IR) and T2DM, but little is known about the role of iron metabolism on adipose tissue. We therefore investigated whether markers of iron metabolism were associated with adipocyte IR and plasma adiponectin. RESEARCH DESIGN AND METHODS: Serum ferritin, transferrin, total iron, non-transferrin-bound iron (NTBI), transferrin saturation, and plasma adiponectin were determined in 492 individuals. Adipocyte IR was defined by the product of fasting insulin and nonesterified fatty acids (NEFAs). Using linear regression analyses, we investigated the difference in adipocyte IR or adiponectin (in %) according to differences in iron metabolism markers. RESULTS: Serum ferritin (ß = 1.00% increase in adipocyte IR per 10 µg/L [95% CI 0.66-1.34]), transferrin (4.18% per 0.1 g/L [2.88-5.50]), total iron (1.36% per µmol/L [0.61-2.12]), and NTBI (5.14% per µmol/L [1.88-8.52]) were associated with adipocyte IR after adjustment for several covariates, including inflammatory markers. All markers of iron metabolism were also associated with NEFAs (all P < 0.01). In addition, ferritin and transferrin were inversely associated with adiponectin (both P < 0.01). CONCLUSIONS: The observed associations of several markers of iron metabolism with adipocyte IR and adiponectin suggest that factors related to iron and iron metabolism may contribute to adipocyte IR early in the pathogenesis of T2DM.

Low-grade inflammation and insulin resistance independently explain substantial parts of the association between body fat and serum C3: the CODAM study.

OBJECTIVE: To investigate the role of low-grade inflammation and insulin resistance (HOMA2-IR) in adiposity-related increases in serum complement factor 3 (C3). Although C3 has been linked to type 2 diabetes and cardiovascular diseases, and C3 levels are closely related to body fat, the underlying mechanisms explaining this association are still unknown. METHODS: Adiposity measures (including BMI, waist circumference (WC), sagittal diameter and several skinfolds), HOMA2-IR and markers of inflammation (hs-CRP, IL-6, SAA, haptoglobin, ceruloplasmin, sICAM-1) were determined in 532 individuals (62% men, mean age 59±6.9 yrs) from the Cohort on Diabetes and Atherosclerosis Maastricht study. Markers of inflammation were standardized and compiled into an averaged inflammation score. Cross-sectional associations between adiposity measures and C3 and the mediating role of low-grade inflammation and/or HOMA2-IR herein were analysed with multiple linear regression models. RESULTS: Adiposity measurements were significantly associated with C3 levels, with the strongest (adjusted) associations found for WC (ß=0.383; 95%CI 0.302-0.464) and sagittal diameter (ß=0.412; 95%CI 0.333-0.490). Further adjustment for inflammation and HOMA2-IR attenuated these associations to ß=0.115 (95%CI 0.030-0.200) and ß=0.163 (95%CI 0.082-0.244) respectively. Multiple mediation analyses showed that inflammation [ß=0.090 (95%CI 0.060-0.126)] and HOMA2-IR [ß=0.179 (95%CI 0.128-0.236)] each explained, independently of one another, a significant portion of the association between WC and C3 (23% and 47%, respectively). Similar mediation by inflammation (19-27%) and HOMA2-IR (37-56%) was found for other adiposity measures. CONCLUSION: Systemic low-grade inflammation and insulin resistance may represent two independent pathways by which body fat leads to elevated C3 levels.

[Diabetes mellitus and cirrhosis of the liver: a prognostically unfavourable combination]. / Diabetes mellitus en levercirrose: prognostisch ongunstige combinatie.

We conducted a literature search to determine the prognostic effect of diabetes in patients with cirrhosis of the liver. We also searched for evidence on diagnosis and treatment of diabetes in these patients. Insulin resistance occurs in obese patients with cirrhosis due to non-alcoholic steatohepatitis, but also develops in patients with alcoholic or viral cirrhosis. Eventually, 20-40% of patients with cirrhosis have manifest diabetes mellitus. Diabetes mellitus may accelerate progression of liver fibrosis to cirrhosis and may lead to higher mortality rates among cirrhosis patients, largely due to infections and liver failure. Treatment of diabetes in patients with chronic liver disease can theoretically improve survival. In treating such patients, doctors should take into account the reduced clearance of insulin and oral antidiabetic agents in the liver.

[Low back pain and MRI-abnormalities: atypical polymyalgia rheumatica]. / Lage rugpijn en MRI-afwijkingen: atypische polymyalgia rheumatica.

A 64-year-old man was admitted to hospital with increasing low back pain, radiating to his upper legs. MRI of the lumbar spine showed inflammatory lesions of vertebrae L3-L5, after which the patient was treated with flucloxacilline for 6 weeks. However, he did not improve and the pain became more extensive. Finally, PET-CT study showed abnormalities in shoulders, back and hips, indicating a probable diagnosis of polymyalgia rheumatica. Upon treatment with prednisone, the pain quickly decreased and 3 months later the inflammatory changes visible on MRI were clearly reduced. Polymyalgia rheumatica (PMR) is often recognized by its typical clinical presentation, but in atypical cases, investigation using imaging may be helpful. Abnormalities in shoulder and hip joints are most common, but signs of cervical and lumbar interspinous bursitis might also be found in patients with PMR.

[Thrombophlebitis of the leg: diagnosis and treatment by the general practitioner]. / Tromboflebitis van het been: diagnostiek en behandeling door de huisarts.

We reviewed the literature for the association between superficial vein thrombosis (SVT) and venous thromboembolism (VTE) and for evidence of treatment of SVT with low-molecular-weight heparin (LMWH). There is some evidence for an association between SVT and VTE. This association seems stronger for proximal SVT as compared with distal SVT. In general practice, the absolute risk of VTE with or after SVT is low, approximately 3%. There is evidence that treatment of SVT with LMWH may have a beneficial effect on its course. NSAIDs have a similar effect. There is indirect evidence that LMWH is effective in the prevention of VTE, if the treatment is continued for more than 4 weeks. In case of a proximal SVT, we suggest an ultrasound examination be carried out and LMWH treatment given if the diagnosis is confirmed; in other cases, NSAIDs can be considered.