Norwalk Hospital

Background: Wound healing relies on a balance between extracellular matrix remodelling by matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs). Among all the MMPs, elevated MMP-9 levels are implicated in chronic wounds including diabetic ulcers, making it a potential biomarker to predict wound healing. This in turn can help determine the need for aggressive wound care management. However, most studies used invasive sampling methods like wound fluid or tissue biopsy limiting clinical implementation. Hence, this study assessed the correlation between serum levels of MMP-9 in diabetic and non-diabetic chronic wounds to explore if non-invasive methods could be used to predict healing in diabetic chronic wounds.Objective: This study aimed to compare serum MMP-9 levels in diabetic vs. non-diabetic chronic wounds, assess correlations with glycemic control (glycated hemoglobin (HbA1c)), and determine the potential of serum MMP-9 as a predictor of healing in diabetic chronic wounds.Methods: This was a cross-sectional study involving 40 patients (20 diabetics, 20 non-diabetics) with chronic wounds. Serum MMP-9 levels were measured from blood samples (avoiding invasive methods) using an enzyme-linked immunosorbent assay (ELISA). HbA1c levels were obtained for patients with diabetes mellitus. Statistical analysis compared means (t-test) and correlations (Pearson's).Results: Patients with diabetes mellitus had significantly higher serum MMP-9 (mean 21.22 ng/ml) in comparison to non-diabetics (17.35 ng/ml; p=0.0023). When compared to only 5% (one out of 20) of non-diabetics, about 75% (15 out of 20) of diabetics had MMP-9 greater than 20 ng/ml. However, no correlation was found between MMP-9 and HbA1c levels (p>0.05) among diabetic patients.Conclusions: Serum MMP-9 is elevated in diabetic chronic wounds, supporting its role as a non-invasive biomarker. Several studies have established wound fluid/tissue MMP-9 as a predictor of healing in diabetic ulcers, and this study suggests that serum MMP-9 levels could be used as a non-invasive biomarker in place of cumbersome methods. However, the lack of association of MMP-9 with HbA1c suggests glycemic control alone may not regulate MMP-9. Targeting MMP-9 inhibition (e.g., via microRNAs) could be a therapeutic strategy, warranting further research.

Ecthyma gangrenosum is a rare dermatological manifestation often linked to Pseudomonas aeruginosa bacteremia, typically occurring in immunocompromised individuals. We present a case of ecthyma gangrenosum in a 69-year-old male with diabetes mellitus, but without HIV, malignancy, or chronic immunosuppressive therapy. The patient exhibited septic shock, pyelonephritis, and pneumonia, and was eventually diagnosed with ecthyma gangrenosum due to systemic Pseudomonas aeruginosa infection. This case highlights the occurrence of ecthyma gangrenosum in an older patient with metabolic comorbidities and age-related immune dysfunction, but without classic immunosuppressive conditions. It underscores the importance of early recognition and intervention in such populations, and the need for a nuanced approach to immune status in elderly patients with diabetes.

BackgroundThe genetic components of the etiologies of ovulatory dysfunction-related infertility (ODRI) are poorly characterized.ObjectivesThis paper aimed to comprehensively identify, compile, and categorize published research on relationships between genetics and ovulatory-related infertility in humans.MethodsA scoping review was performed on research articles relating human genes, ovulatory dysfunction, and infertility retrieved from PubMed and Web of Science databases. A total of 45 articles were included in the study. The data has been organized into three categories based on relevant findings: polycystic ovary syndrome (PCOS), premature ovarian insufficiency (POI), and other diagnoses related to ovulatory dysfunction and infertility.ResultsSources revealed 235 different genes linked to ovulatory dysfunction and infertility including follicle-stimulating hormone receptor (FSHR), luteinizing hormone/choriogonadotropin receptor (LHCGR), and bone morphogenic protein 15 (BMP15). PCOS-related articles revealed variants in genes with functions focused on androgen production, such as LHCGR and FSHR. POI-related articles revealed variants in genes with functions focused on folliculogenesis and pubertal development, such as BMP15 and STAG3, stromal antigen 3. The “other” category revealed genes resulting in enzyme deficiencies interacting with a wide range of functions.ConclusionsIn this review, we have highlighted the extreme variability in what is known about the genetics of ODRI by compiling and categorizing genes identified in the literature as associated with ODRI and its associated subtypes. We have also provided a comprehensive list of ODRI genes specifically identified in humans. The findings from this review, specifically the list of ODRI genes, can be used for targeted gene panel development in assisted reproductive technology to improve clinical testing and diagnosis, as well as in developing individualized treatment strategies for ODRI patients.

Brucellosis, a zoonotic infection typically presenting with nonspecific symptoms, rarely leads to cardiac complications, particularly conduction abnormalities. We report a unique case of an 84-year-old female who presented with dizziness, bradycardia, and hypotension, ultimately diagnosed with complete heart block. On admission, blood cultures and further diagnostic workup identified Brucella bacteremia as the underlying cause, with further history revealing that she had recently traveled from a farm in Colombia, a brucellosis-endemic area. The patient underwent dual-chamber pacemaker implantation to stabilize her heart rhythm and was initiated on a three-month antibiotic regimen of doxycycline and rifampin. This case highlights the importance of considering brucellosis as a differential diagnosis for heart block in patients with recent travel from endemic regions. Early recognition and intervention, including antibiotic therapy and pacemaker placement when necessary, are essential for achieving favorable outcomes in brucellosis-related cardiac complications.

Introduction. Biological disease-modifying antirheumatic drugs (bDMARDs), such as tocilizumab (TCZ), are essential for reducing disease activity in moderate to severe rheumatoid arthritis (RA). This study aims to identify clinical and laboratory predictors of a favorable response to TCZ, enabling personalized therapeutic strategies. Material and methods. A longitudinal clinical study in dependent samples included 133 bio-naïve patients (121 women, 12 men, mean age 49.87±13.31 years) with seropositive RA (radiological stages I-III) treated with TCZ and csDMARDs at the Timofei Moșneaga Republican Clinical Hospital. Clinical and laboratory parameters were monitored monthly over a six-month period. Statistical analysis was performed using Spearman’s correlation and multiple regression. The Wilcoxon signed-rank test was applied to compare parameters before and after TCZ treatment. Results. Favorable response predictors included swollen joint counts (ρ=0.59, p<0.01), tender joint counts (ρ=0.40, p<0.01), C-reactive protein (ρ=0.46, p<0.01), ESR (ρ=0.25, p<0.01), platelet count (ρ=0.29, p<0.01), hemoglobin (ρ=-0.26, p<0.01), hematocrit (ρ=-0.23, p<0.01), and age (ρ=-0.49, p<0.01). Regression analysis confirmed the influence of swollen joint counts (ρ=0.30, p<0.001), age (ρ=-0.30, p<0.001), and C-reactive protein (ρ=0.18, p=0.016) on DAS28 reduction. Conclusions. Swollen and tender joint counts, C-reactive protein, and age are key independent predictors of therapeutic success with TCZ after six months of treatment.

Unhurried conversations are necessary for careful and kind care that is responsive and responsible to both patients and clinicians. Adequate conceptual development is an important first step in being able to assess and measure this important domain of quality of care. In this article, we expand on a preliminary model to identify the key microlevel communication practices that support an unhurried conversation, defined as an ongoing, mutual accomplishment between patient and clinician that proceeds through a range of verbal and nonverbal communication practices wherein one or more participants (mutually) regulate the sequence, spacing (temporal and spatial), and speed of interaction to make themselves available to the other and remove or suspend distractions from the environment in order to improve care. We draw from the rich, qualitative descriptions found in earlier work that point to specific, observable practices in clinical encounters and identified empirical and theoretical work across a range of disciplines to expand our understanding of these practices. Ultimately, we identify and elaborate on 10 observable indicators of patient-clinician communication: engaging in shared turn taking, establishing rapport through discussion of off-task topics, pausing to allow the other ample time to speak, moderating the pace of spoken language, avoiding conversational interruptions, minimizing external interruptions, triaging topics as needed to create adequate time, expressing emotions, encouraging participation through inviting questions, and displaying open body language. These indicators work together to cocreate unhurried conversations.