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  • Treasury yields hold steady as investors await Fed meeting minutes

    Treasury yields hold steady as investors await Fed meeting minutes

    U.S. Treasury yields held steady on Wednesday as investors awaited the Federal Reserve’s meeting minutes from July and for more insights about the path of monetary policy.

    At 5:45 a.m. ET, the 10-year treasury yield rose less than a basis point to 4.304%, and the 2-year yield was also little changed at 3.758%.

    One basis point is equal to 0.01% and yields and prices move in opposite directions.

    Investors are anticipating the Fed’s meeting minutes from its Federal Open Market Committee meeting in July, where policymakers decided to keep interest rates unchanged. The meeting minutes are particularly in focus as Fed Governors Christopher Waller and Michelle Bowman dissented on the decision, the first time two voting Fed officials have done so since 1993.

    Global central bankers will gather in Jackson Hole, Wyoming, from Thursday to Saturday for the Fed’s annual economic symposium, which investors will monitor for hints about future monetary policy decisions. Fed Chairman Jerome Powell is slated to give a speech on Friday at the symposium.

    Traders are pricing in a nearly 83% chance of interest rate cuts in September, per the CME’s FedWatch Tool.

    “We expect this year’s Jackson Hole meeting to offer an opportunity for Powell to again nod towards monetary easing,” said Andrzej Skiba, head of the BlueBay U.S. Fixed Income team at RBC Global Asset Management. “While there are some hot spots in this month’s inflation reading, it’s probably not enough to deter the doves on the committee.”

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  • Cerebrovascular diseases in ADHD patients with metabolic comorbidities: a retrospective cohort study | BMC Psychiatry

    Cerebrovascular diseases in ADHD patients with metabolic comorbidities: a retrospective cohort study | BMC Psychiatry

    This study provides novel insights into the association between ADHD and cerebrovascular disease (AIS; TIA), particularly in adults aged 45 and older with metabolic comorbidities. Our findings indicate that individuals with ADHD had a higher cumulative incidence of TIA and AIS compared to controls, with the association being particularly pronounced in those with obesity, hypertension, or dyslipidemia. These results align with prior research demonstrating an increased cardiovascular burden in ADHD patients, although most previous studies have focused on younger populations and the immediate cardiovascular effects of stimulant medication rather than cerebrovascular outcomes in adults [5, 17].

    Zhang et al. recently conducted a large-scale case-control study using Swedish national registry data and reported an increased incidence of cardiovascular diseases, including cerebrovascular events, among ADHD patients with long-term stimulant use [17]. Their analysis demonstrated a 4% increase in cardiovascular disease incidence per additional year of ADHD medication use, with the greatest risk occurring within the first three years of treatment. Notably, prolonged medication exposure (> 5 years) was significantly associated with hypertension and arterial disease, both of which are established risk factors for cerebrovascular disease [17]. While these findings emphasize the importance of long-term cardiovascular monitoring in ADHD patients, the study did not fully differentiate between the direct impact of ADHD itself and the modifying role of pharmacotherapy [17]. Our results suggest that ADHD may be associated with cerebrovascular diseases, particularly in individuals with metabolic disorders; however, given the potential influence of unmeasured confounders, further research is needed to clarify the mechanisms underlying this association.

    The potential biological pathways linking ADHD and cerebrovascular disease likely involve a complex interplay of metabolic dysregulation, vascular dysfunction, and behavioral factors [16, 22, 23]. ADHD has been associated with an increased prevalence of lifestyle-related risk factors, including smoking, physical inactivity, and unhealthy dietary habits [22, 23], all of which contribute to metabolic syndrome and cardiovascular disease [24]. Additionally, ADHD has been linked to autonomic dysregulation, which may influence vascular tone and hemodynamic stability, further exacerbating cerebrovascular risk [16].

    Stimulant medications commonly prescribed for ADHD are known to increase blood pressure and heart rate. A meta-analysis by Mick et al. reported a mean increase of 5.7 beats per minute in resting heart rate and a 2.0 mmHg rise in systolic blood pressure among ADHD patients receiving stimulant therapy [4]. While these changes may appear modest, even slight elevations in blood pressure over time could contribute to cerebrovascular burden, particularly in individuals with pre-existing vascular risk factors [25]. However, Shin et al. found no significant association between ADHD medication and cerebrovascular disease in pediatric and adolescent populations, suggesting that vascular changes in adulthood, rather than stimulant-related effects alone, may play a more critical role in cerebrovascular outcomes [5].

    The observed association between ADHD and cerebrovascular diseases appears to be amplified in individuals with metabolic disorders. Insulin resistance, chronic inflammation, and lipid dysregulation are key contributors to atherosclerosis and cerebrovascular pathology [26]. The metabolic score for insulin resistance (METS-IR) has been identified as a predictor of stroke risk in hypertensive patients, reinforcing the hypothesis that metabolic impairments may mediate cerebrovascular outcomes [26]. Although METS-IR was not specifically assessed in our study, the significant interaction between ADHD and metabolic comorbidities suggests that future investigations should explore the role of insulin resistance and lipid metabolism in ADHD-related cerebrovascular diseases.

    Several limitations must be considered when interpreting the findings of this study. The reliance on ICD-10 coding means that conditions such as obesity, diabetes, and hypertension were identified based on general practice documentation rather than objective clinical measurements (e.g., BMI, laboratory values), which may have introduced misclassification. Additionally, diagnoses typically made in hospital, such as AIS and TIA, are often recorded retrospectively in general practice — only after this would the corresponding ICD-10 code appear in our dataset, potentially leading to underreporting of outcomes. The use of 1:5 propensity score matching improved comparability and statistical power but may have introduced residual differences between the groups, potentially affecting generalizability. Furthermore, information on ADHD symptom severity was not available, preventing an analysis of whether more severe ADHD cases were disproportionately associated with cerebrovascular diseases. Similarly, data on ADHD pharmacotherapy were inaccessible, as stimulant and non-stimulant medications are primarily prescribed by psychiatrists rather than general practitioners. This limitation precluded an assessment of the potential impact of ADHD treatment on cerebrovascular risk.

    Additionally, key lifestyle factors (e.g., smoking status, physical activity, diet)—which are well-established contributors to cerebrovascular risk—were not available in the dataset, increasing the possibility of residual confounding. Given the retrospective observational design, causality cannot be established, and unmeasured confounders may have influenced the observed associations.

    Despite these limitations, this study has several strengths. The large sample size enabled robust statistical analyses and improved generalizability. The application of propensity score matching accounted for key confounders such as age, sex, and metabolic comorbidities, enhancing the validity of comparisons between ADHD and non-ADHD individuals. The long follow-up period of up to ten years provided valuable insights into long-term cerebrovascular risks associated with ADHD, particularly in older adults and those with metabolic conditions. Furthermore, detailed subgroup analyses helped elucidate how metabolic comorbidities interact with ADHD in relation to cerebrovascular diseases.

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  • Spironolactone and Dialysis: Major Trial Finds No Benefit

    Spironolactone and Dialysis: Major Trial Finds No Benefit


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    A large international study has found that spironolactone, a medication for high blood pressure and heart failure, does not reduce the risk of heart-related death or hospitalizations in people with kidney failure receiving dialysis, despite earlier smaller studies suggesting benefit.


    The study – led in the UK by the University of Glasgow and published in The Lancet – are part of the ACHIEVE trial, the largest trial to date on the drug spironolactone in people receiving dialysis.

    Globally, an estimated 2.5 million people receive dialysis for kidney failure. Heart disease is the leading cause of death in this population, responsible for about 40 per cent of all deaths.

    Unfortunately, the study found that spironolactone showed no cardiovascular benefit in this group of patients, and it increased the risk of severe hyperkalaemia, a rise in blood potassium levels that can lead to irregular heart rhythms or even death in extreme cases.

    For the study, 2,538 participants were enrolled from 143 dialysis centres across 12 countries. All participants had been on dialysis for at least three months and were either over 45 years old, or over 18 with diabetes.

    The UK arm of the ACHIEVE trial was led by Professor Paddy Mark of the University of Glasgow and funded by the British Heart Foundation.

    Clinical teams and patients from dialysis centres across all four nations of the UK took part in this important clinical trial, and their participation ensured the successful, on-schedule completion of the global trial.

    Researchers tested whether a low daily dose (25 mg) of spironolactone could block aldosterone, a hormone that causes heart remodeling, fibrosis, and raises cardiovascular risk. They wanted to see if this treatment could lower the risk of cardiovascular death or hospitalization for heart failure in patients with kidney failure.

    Patrick Mark, Professor of Nephrology at the University of Glasgow’s School of Cardiovascular Health and Metabolic Medicine, said: ‘Although the trial result was neutral, this is another crucial piece of information which will help the quest to improve outcomes for people with kidney failure treated with dialysis”

    Michael Walsh, principal investigator of the study and senior scientist at the Population Health Research Institute (PHRI), a joint institute of McMaster University and Hamilton Health Sciences, said: “In people with normal kidney function, spironolactone reduces cardiovascular events. However, people receiving dialysis might not respond the same way to treatments proven effective in the general population.

    “We launched the ACHIEVE study to determine the safety and effectiveness of spironolactone in people with kidney failure. Aldosterone plays a harmful role in heart disease, and its levels tend to be high in dialysis patients. That’s why we thought spironolactone might help.”

    The trial began recruiting in 2018 and concluded in December 2024. Of the 3,565 patients recruited, 2,538 who tolerated the drug during a seven-week run-in period were randomly assigned to receive either 25 mg of spironolactone daily or a placebo. The trial was stopped early for futility after an independent monitoring committee determined there was little chance of seeing a meaningful benefit.

    Cardiovascular death or hospitalization for heart failure occurred in 258 patients in the spironolactone group, compared to 276 in the placebo group. The difference was not statistically significant. The study noted a potential difference in these incidents between men and women, although more research is needed to understand why. Severe hyperkalaemia occurred more often in the spironolactone group: 6.6 per cent of patients in the spironolactone group, compared to 4.5 per cent in the placebo group.

    Michael Walsh added: “We really hoped that spironolactone could make a difference for people on dialysis. While the results are not what we wanted, they provide much-needed clarity. This study moves us one step closer to finding effective and safe treatments for a group that urgently needs them.”

    Reference: Walsh M, Collister D, Gallagher M, et al. Spironolactone versus placebo in patients undergoing maintenance dialysis (ACHIEVE): an international, parallel-group, randomised controlled trial. The Lancet. 2025;406(10504):695-704. doi: 10.1016/S0140-6736(25)01198-5

    This article has been republished from the following materials. Note: material may have been edited for length and content. For further information, please contact the cited source. Our press release publishing policy can be accessed here.

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  • How to apply for CM Punjab E-Taxi Scheme 2025 – ARY News

    1. How to apply for CM Punjab E-Taxi Scheme 2025  ARY News
    2. Payment Structure of Punjab E-Taxi Program Revealed  ProPakistani
    3. CM speaks about importance of e-buses  Business Recorder
    4. Punjab receives 100 Chinese Electric Buses for less developed districts Breaking  Independent News Pakistan
    5. Punjab govt set to roll out first e-taxi service  SUCH TV

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  • Infrastructure in Movies: From Golden Gate to Glenfinnan Viaduct

    Infrastructure in Movies: From Golden Gate to Glenfinnan Viaduct

    If there’s one piece of infrastructure that cinema loves to destroy, it’s the Golden Gate Bridge. The famous bridge in San Francisco collapses under Godzilla’s attack in Godzilla (2014), is swept away by a tsunami in San Andreas (2015), and is torn in half in X-Men: The Last Stand (2006) when a mutant lifts it to access Alcatraz.

    Built between 1933 and 1937, the Golden Gate Bridge stretches 2.7 km long and rises 227 meters high. But above all, it’s a strategic structure for the San Francisco Bay Area. According to the Golden Gate Bridge Highway & Transportation District, 112,000 vehicles cross it every day, and in 2024, tolls alone generated $154.3 million.

    A unique piece of engineering marvel—and a global icon—visited by 10 million people annually. Tourism in the Golden Gate Recreation Area contributes $1.5 billion a year to California’s economy.

    Its beauty and recognizability have made it not only one of the most famous bridges in the world, but also a favorite of filmmakers, who often use it as a symbol of catastrophe and rebirth.


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  • Intraoperative Magnetic Resonance Imaging Complications Leading to Remote Intracerebral Hemorrhagic Infarction Following a Glioblastoma Resection: A Case Report and Lessons for Clinical Practice

    Intraoperative Magnetic Resonance Imaging Complications Leading to Remote Intracerebral Hemorrhagic Infarction Following a Glioblastoma Resection: A Case Report and Lessons for Clinical Practice


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  • Why the new Amanda Knox TV drama is misguided

    Why the new Amanda Knox TV drama is misguided

    Another grating element is the way the story is overlaid by the kind of irreverent millennial narration, from Van Patten as Knox, which recalls other recent true-crime dramatisations such as Inventing Anna or Apple Cider Vinegar. In trying to ape the style of these other “lighter” shows, it takes away from the severity of the actual case in hand. 

    The wave of ‘reclaiming’ narratives 

    However, after the gross injustice of being framed for a murder you didn’t commit, it’s understandable why Knox would want to put the story straight once more – and “reclaim” her narrative. This is something which a host of pop culture documentaries, podcasts and dramatisations have purportedly helped famous women to do over the past decade, casting a new light on ’90s female celebrities and figures like Britney Spears, Pamela Anderson, Monica Lewinsky and Tonya Harding, who were caught up in scandals that saw them demonised in a public forum.

    Even in the short tribute to Kercher at the end of the series, Knox is once again the main focus

    Interestingly, Lewinsky is an executive producer on The Twisted Tale of Amanda Knox, alongside Knox herself, having co-produced Ryan Murphy’s 2021 miniseries Impeachment: American Crime Story, which retold the story of her affair with the then US President Bill Clinton from her perspective. Some of these projects, like the Lewinsky drama, have been done with the involvement of their subjects, and some, like Hulu’s Pam and Tommy, about Pamela Anderson’s sex tape scandal, have been done without. However as Jessica Bennett asked in The New York Times of this whole sub-genre of “reclaiming the narrative” productions: “It is no secret that humans love consuming spectacle – and we doubly love a spectacle when it involves women and sex. But at what point does the fictional depiction of that spectacle, and our viewing of it, become just as bad as watching it in the first place?”

    Knox has said that the series is intended to highlight that the real killer was Guede, which is valid point – given that Guede was given a “fast track” trial and convicted for the murder out of the public eye, without being subjected to the same intense media scrutiny as Knox. She recently told Newsweek: “No one cares about this guy who actually murdered my roommate. I think that is so indicative of what was going on at the time, and has always been going on with this case, [which] is the idea that it wasn’t ever even really about Meredith… The truth of what happened to her, and the truth of the person who actually did it, got completely lost for the sake of a scandalous story.”

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  • Fasting supports type 1 diabetes care by reshaping the microbiome

    Fasting supports type 1 diabetes care by reshaping the microbiome

    A week of supervised fasting temporarily reshaped the gut microbiome of people with type 1 diabetes, making it resemble that of healthy individuals, and improving cholesterol and weight without causing dangerous side effects.

    Study: Fasting elicits gut microbiome signature changes that extend to type 1 diabetes patients. Image credit: EchelonIMG/Shutterstock.com

    Type 1 diabetes (T1D) is a chronic disease that affects nine million people worldwide. It is marked by a deficiency of the glucose-lowering hormone insulin, produced in the pancreatic beta cells. A new report in Frontiers in Endocrinology tested the role of prolonged therapeutic fasting as a complementary treatment for T1D.

    Introduction

    T1D is managed with lifelong insulin therapy to replace beta-cell function, coupled with careful dietary management. These patients are at high risk for multiple other medical conditions, including cardiovascular disease.

    T1D is a complex disease with underlying genetic and environmental factors. It has become more common in Western societies over the last three decades, suggesting the enhanced role of environmental factors in its causation. In these patients, the gut microbiome shows differences in composition and function compared to healthy controls, both before and after the onset of the disease.

    Apart from the increased gut permeability in T1D, these differences could be due to the shared risk factors for autoimmune diseases (such as T1D) and gut dysbiosis. These include the mode of birth, diet, infections, antibiotic exposure, and mental stress.

    All these factors cause a loss of beneficial gut bacteria and their metabolites. For instance, metabolites like short-chain fatty acids (SCFA) and immunomodulatory metabolites contribute to gut health by maintaining the balance of regulatory T cells and pro-inflammatory Th17 cells. They also preserve the integrity of the gut’s epithelial barrier, keeping toxins and pathogens out of the body and the blood.

    Such negative interactions in early life may predispose to colonization by pathogens, leading to intestinal inflammation. Other gut microbes may trigger autoimmunity by expressing antigenic sites closely resembling self-antigens, known as “molecular mimicry”. For example, Parabacteroides distasonis contains a sequence similar to an important insulin epitope. Its presence is associated with higher rates of T1D development in mice and children.

    Besides insulin, approaches to managing T1D focus on slowing down beta cell destruction with immunomodulators and biologicals. These are costly, with significant side effects, and are required lifelong, like insulin.

    Therapeutic fasting is a nutritional approach that improves the symptoms of multiple autoimmune diseases and alters the gut microbiome profile in healthy individuals. The question in this study was whether such changes also occur in T1D patients. Studies on fasting, including the month-long Ramadan fast observed by Muslims or a seven-day supervised fast, have shown their safety in selected T1D patients at least. Restricting metabolic fuel can rapidly weaken the autoimmune response, lending biological plausibility to this hypothesis.

    In mouse models, repeated fasting cycles reduce the risk of autoimmunity and enhance beta cell regeneration and Treg proliferation. Fasting also affects the gut microbiome in mouse studies. For instance, it leads to the production of β-hydroxybutyrate, an important fuel molecule during fasting. This depletes Bifidobacteria, reducing intestinal Th17 activity.

    Several species experience fasting-related shifts in abundance. It is possible that restricting dietary nutrients promotes the proliferation of gut microbes with a more diverse metabolic portfolio, enabling them to switch to host-derived nutrients.

    Study findings

    The current pilot study included 19 T1D patients and ten controls, primarily female. The mean body mass index (BMI) was 27.7 kg/m2 and 26.2 kg/m2, respectively.

    Prolonged fasting periods acutely changed the gut microbiome’s structure and composition in T1D patients, leveling it with that in controls. Immediately after the end of the fasting period, the gut microbiome closely resembled that of non-diabetic controls, but no long-term shift was established. Diabetic ketoacidosis did not occur with fasting in the T1D group.

    Several fiber-associated Lachnospiraceae decreased, while mucin/glycosaminoglycan-degrading Lachnospiraceae and some Oscillospiraceae increased during fasting. These are among the largest producers of the SCFA butyrate, thriving on a fiber-rich diet, and typically break down fiber. As a result, these members may not thrive in fiber-deficient periods, as during fasting periods.

    The fasting regimen in this study involved ~200 kcal/day of juices and broth, which provided very little dietary fiber. This could help explain why fiber-adapted taxa declined while mucin-degrading taxa thrived.

    However, not all members of these families change the same way. Other taxa that break down mucin and glycosaminoglycans increase in response to fasting, as reported in different studies. This indicates a shift towards using host-derived energy sources, including β-hydroxybutyrate.

    These taxonomic changes were correlated with fasting-related alterations in blood pressure and cholesterol levels. Both the BMI and the ratio of bad-to-good cholesterol (low-density lipoprotein, LDL, and high-density lipoprotein, HDL, respectively) improved during the fasting period and follow-up. This change was similar to that reported earlier in non-diabetic patients.

    In controls, post-fast patterns mirrored those in T1D but did not reach statistical significance, likely due to the small sample size.

    When compared with a small group of ten multiple sclerosis patients on repeated prolonged fasting, many areas of the gut microbiome picture showed overlaps, as did autoimmunity-free groups.

    This suggests that fasting’s effects on the microbiome are independent of the host’s health status and the type of disease, though larger studies are needed to confirm this. The gut microbiome responds to fasting in a conserved manner, probably because the gut microbes are forced to use diverse metabolic pathways to utilize host-derived nutrients.

    While the taxa that break down dietary sources of energy decrease in abundance during fasting, those that can switch to using other energy substrates thrive. “This suggests that, next to utilizing β-hydroxybutyrate for their own nutrition, the gut microbiota could play an important role in augmenting host ketone production during periods of fasting.”

    Specific taxa that increase during fasting may induce immune tolerance to environmental stimuli, perhaps contributing to the reduced inflammation with fasting.

    Conclusions

    The findings of this study demonstrate that “fasting under medical supervision is safe and could prove beneficial for patients with T1D.” The results suggest that the gut microbiome is shaped by nutrient availability rather than the presence of disease.

    The associations with clinical outcomes emphasize the need to explore the causal connections between gut microbiome changes and the reported clinical improvements with fasting. More research is needed to understand the long-term value of fasting as an adjunctive treatment in these patients. Moreover, the speed with which microbial restoration occurs during re-feeding also needs to be explored.

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  • A rare case of coinfection of Rhodococcus equi and Nocardia abscessus

    A rare case of coinfection of Rhodococcus equi and Nocardia abscessus

    Introduction

    Rhodococcus equi, previously known as Corynebacterium equi, is a gram-positive, aerobic, intracellular, nonmotile, and weakly acid-fast coccobacillus that belongs to the genus Rhodococcus within the Nocardiaceae family.1 R. equi, an emerging zoonotic pathogen, was first reported in 1967 as a human pathogen.2 It mainly presents with pulmonary diseases, such as necrotizing pneumonia and lung abscesses,3 but can also involve extrapulmonary organs, such as brain abscesses.4 R. equi can cause rare, potentially fatal diseases, predominantly affecting patients who are immunocompromised5 and has been reported in patients with competent immune systems as well.6

    Nocardia spp. are aerobic, branched, gram-positive bacteria with partial acid tolerance that are frequently isolated from soil and typically cause opportunistic infections in immunocompromised hosts. However, multiple case reports have demonstrated that Nocardia spp. cause various forms of disease in immunocompetent patients as well, such as pulmonary,7 lymphocutaneous,8 pyomyositis,9 and brain abscesses.10 Thirteen species of Nocardia, including Nocardia abscessus, Nocardia farcinica, Nocardia brasiliensis, Nocardia asteroids, and Nocardia otitidiscaviarum are the most common causes of human infections.11

    Here, a coinfection of R. equi and N. abscessus is described in a Chinese man who presented immunocompetence as well as the treatment therapy used. This report is rare of its kind.

    Case Presentation

    Clinical Features

    A 52-year-old man was presented to our hospital due to trauma with pain and swelling of the right hand and that symptoms got worse over the past 10 days. The patient accidentally injured his hand using a hydraulic press at work 10 days ago. He experienced sharp pain, and a small amount of hydraulic oil was squeezed from his right palm. Without any special treatment, the skin of the right palm was swollen with acute pain, and active flexion and extension of his fingers were limited. When the patient arrived, physical examination and medical history examination were performed, with no history of hypertension, diabetes mellitus, food and drug allergies, and the abdomen was soft. The patient’s temperature was 37.2°C. A sinus was observed between the 4th and 5th metacarpal bones of the right palm, and the skin of the right hand showed obvious swelling with a high temperature. Pressure pain around the sinus opening was apparent, the 3–5 fingers of the right hand were limited in active flexion and extension due to pain, and the distal end of the affected limb had good peripheral blood flow but was slightly numb (Figure 1A).

    Figure 1 (A) A sinus was observed between the 4th and 5th metacarpal bones of the right palm. (B) Imaging examination. Ultrasound scanning of the dorsolateral aspect of the right hand showed an uneven echogenic area of about 3.5 cm × 1.3 cm × 0.9 cm in the deep surface of the extensor muscles between the 4th and 5th metacarpals.

    Abnormal elevation of white blood cell (WBC) count (15.73×109 cells/L) with 78% neutrophils and C-reactive protein (CRP) (52.78 mg/L) was indicated by blood routine examination. The clinical and laboratory findings are summarized in Table 1.

    Table 1 Clinical and Laboratory Variables of the Patient

    Imaging Examination

    Ultrasound scanning of the dorsolateral aspect of the right hand showed an uneven echogenic area of about 3.5 cm × 1.3 cm × 0.9 cm in the deep surface of the extensor muscles between the 4th and 5th metacarpals, with blurred borders, speckles of strong echoes and small patches of fluid echoes and the pressurized probe could be flowed, indicating that it was abscess (Figure 1B).

    Debridement

    The patient underwent right hand debridement and negative pressure suction under brachial plexus anesthesia. A longitudinal incision was made between the 4th and 5th metacarpals on the back of the right hand, and the skin and subcutaneous tissues were incised sequentially. A large amount of purulent discharge and necrotic tissue was detected, and the interosseous muscles were involved. The dorsal purulent secretion and necrotic tissue were completely removed. A serrated incision was made between the 4th and 5th metacarpal bones of the right palm, and the skin and subcutaneous tissue were incised sequentially. A large amount of purulent discharge and necrotic tissue was detected, and the tendon sheath of the flexor tendon of the ring finger was involved. Thoroughly remove the purulent and necrotic tissue on the palmar side. Repeatedly flush the wound with large amounts of saline and dilute iodophor, thoroughly stop bleeding and then cover the wound with VAC dressing, external negative pressure suction and sterile dressing. Bacterial cultures of the purulent discharge and necrotic tissue were performed.

    Etiological Examination

    Specimens were handled and identified according to standard laboratory protocols. After the pus and necrotic tissues were cultured on the Columbia blood agar plate (BAP) at 37°C for 3 days under aerobic conditions, two different forms of colonies could be seen (Figure 2A). Gram staining and acid-fast staining were performed on the creamy white, irregular, and wrinkled colonies, and the observation under the oil microscope showed that it was gram-positive rod and partially acid-fast, suggesting that it was likely to belong to Nocardia spp. (Figure 2B and C). The other yellowish and mucoid colonies were characterized as gram-positive cocci or coccobacillus (Figure 2D). The two forms of colonies were identified by Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) (Zybio, China) as Nocardia abscessus with a reliable score value of 2.26 (Figure 2E) and as Rhodococcus equi with a reliable score value of 2.08 (Figure 2F). The germ identification results were confirmed by 16S rRNA gene sequencing (Tsingke Co., Ltd., Beijing, China).

    Figure 2 Pathogenic examination. (A) Two different forms of colonies were observed by culture on the blood plate. (B) The creamy white, irregular colonies indicated by the green arrow in Figure 2A showed gram-positive rod-shaped bacterium under oil mirror (×1000 magnification). (C) Acid fast staining showed weak positive mycelia, which proved that it was probably Nocardia spp. (D) The yellowish, mucoid colonies indicated by the red arrow in Figure 2A showed gram-positive cocci or coccobacillus bacterium under oil mirror (×1000 magnification). (E) Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) confirm the colony indicated by the green arrow in Figure 2A was Nocardia abscessus. (F) Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) confirm the colony indicated by the red arrow in Figure 2A was Rhodococcus equi.

    The minimal inhibitory concentration (MIC) of the isolated N. abscessus strain against amikacin, cefotaxime, and ceftriaxone was used in the Epsilometer test (E-test) method, and the maximum zone of inhibition against amoxicillin-clavulanic acid, trimethoprim/sulfamethoxazole and minocycline were performed by Kirby–Bauer method (KB). Antibiotic susceptibility results of the N. abscessus were judged by the Clinical and Laboratory Standards Institute (CLSI) interpretive breakpoints. The isolated strain N. abscessus was sensitive to amikacin (Table 2). R. equi is a rare bacterium that lacks a standardized drug-sensitive breakpoint. Therefore, no antimicrobial susceptibility testing was performed.

    Table 2 Antimicrobial Susceptibility of the Nocardia abscessus by Kirby–Bauer Method and Epsilometer Test

    Medication and Prognosis

    When the patient arrived at our hospital, he was treated empirically with piperacillin/tazobactam sodium to prevent infection. Antibiotic use was adjusted after 4 days based on secretion culture results and antibiotic sensitivity, piperacillin/tazobactam sodium was discontinued, and levofloxacin (300 mg/day) and sulfamethoxazole (2 tablets q12h) were initiated. Approximately two weeks after the initiation of this treatment regimen, the patient’s clinical symptoms improved significantly. The patient was discharged for oral sulfamethoxazole therapy and routine follow-up. Two weeks after discharge, the patient completed the medication regimen and was stable at outpatient follow-up with no evidence of infection.

    Discussion

    Rhodococcus and Nocardia spp. are aerobic, gram-positive bacteria that are found globally in soil, dust, and marine sediments. They usually manifest as opportunistic infections in immunocompromised hosts, especially those infected with HIV.1 Our patient was deemed immunocompetent after a workup including HIV screening as well as testing for immunoglobulins and complement resulted as normal. The case presented here is the first report describing a rare R. equi and N. abscessus coinfection in a patient with normal immune system in China.

    In humans, R. equi primarily invades the lungs, causing pneumonia and suppurative lesions. In addition, R. equi can also occur in extrapulmonary organs, such as the kidneys and brain, resulting in bronchitis, meningitis, bacteremia, and other diseases.12 It is acquired through inhalation, ingestion, or inoculation of wounds.13 Currently, there is no standardized drug-sensitive breakpoint for R. equi. Because R. equi resides in cells, at least one antibiotic with good intracellular penetration is recommended.5 Rifampin, imipenem, vancomycin, ciprofloxacin, and erythromycin exhibit good antibiotic activity against R. equi.14

    An increasing number of infections are caused by Nocardia spp., but infections caused by N. abscessus are rare in humans. N. abscessus, previously known as Nocardia asteroides type 1, was first classified in 2000.15 Nocardia cyriacigeorgica and Nocardia farcinica are considered the main pathogenic species worldwide, while in China, Nocardia asteroides is commonly found.16 Nocardia is typically found in the environment, especially in the soil, decaying plants, and standing water. Nocardia can enter the human body through the respiratory tract or skin wounds, causing local infections and spreading to other organs through blood circulation.17,18 Our patient was likely exposed to a high burden of bacteria after injuring his hand by a hydraulic press, while a large number of bacteria entered the wound along with the hydraulic oil. Direct inoculation being is the source of bacteria entry. It is important to tailor the antibiotic therapy by identifying the species level of Nocardia, as the resistance profile can differ significantly across strains. Nocardia can be identified accurately using MALDI-TOF MS or 16S rRNA sequencing.19,20 MALDI-TOF MS is more commonly used than 16S rRNA sequencing because of its short time and ease of use. In this case, filamentous shapes were observed on gram staining and partially positive on modified acid-fast staining, which aided in the identification of Nocardia. Eventually, Nocardia species were identified accurately using MALDI-TOF MS. The results were confirmed using 16S rRNA gene sequencing. N. abscessus is generally susceptible to multiple antibiotics, including trimethoprim/sulfamethoxazole, ceftriaxone, amikacin, amoxicillin-clavulanic acid, and tigecycline. It demonstrates variable susceptibility to imipenem, minocycline, ciprofloxacin, moxifloxacin, and clarithromycin/azithromycin.21

    The patient was treated with levofloxacin, which has excellent intracellular penetration, and sulfamethoxazole, which ultimately proved to be effective. The patient showed good results and recovered from the disease.

    Conclusion

    In conclusion, this is the first report of R. equi and N. abscessus coinfection in a patient with normal immune system in China. The R. equi and N. abscessus isolates were successfully identified by MALDI-TOF MS, which provided a new option for the identification of R. equi and Nocardia. After timely and appropriate anti-infection treatment, the patient’s condition improved and was discharged. This case shows that precise species identity provides a critical guide for physicians in the choice of targeted treatment.

    Ethics Approval and Consent to Participate

    This case report was approved by the ethical review committee of Liaocheng Second People’s Hospital. The patient’s written informed consent was obtained for publications of all the images and case details. No institutional approval was required to publish the case details.

    Author Contributions

    All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

    Funding

    No financial support was received for this article.

    Disclosure

    The authors declare no conflicts of interest in this work.

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  • Kelly Clarkson’s ex-husband Brandon Blackstock honored by family

    Kelly Clarkson’s ex-husband Brandon Blackstock honored by family

    Photo: Kelly Clarkson’s ex Brandon Blackstock family in tears as they honor him in private ceremony

    Kelly Clarkson’s ex-husband Brandon Blackstock’s family and closest friends have reportedly come together in Montana to honor his life days after he lost a three-year battle with cancer

    As per the latest findings of US Weekly, “Brandon’s closest friends and family gathered over the weekend for a few days to celebrate his life in the place he loved most. It was very private.”

    The source even the outlet, “His partner, Brittney [Marie Jones], his family and his closest friends spent time at his home sharing memories of Brandon and remembering how much he meant to them.”

    The insider added, “It was sad and there were tears, but there were also a lot of laughs remembering Brandon’s pranks and sense of humor.”

    “Spending time in Montana walking and hiking the roads Brandon loved so much, and gathering at his home to remember him, was very special for everyone,” the source continued.

    This tribute comes after Brandon, the ex-husband of Kelly Clarkson, was officially confirmed to have passed away after battling cancer for three years. 

    Records released on Wednesday, August 13, by the Butte-Silver Bow County Clerk and Recorder’s office in Butte, Montana, showed that the talent manager died at his home at 11:13 a.m. on August 7 at the age of 48.

    Additionally, seizures were listed as “significant conditions contributing to death but not resulting in the underlying cause.”


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