Early-Cannulation Arteriovenous Grafts Are Safe and Effective in Avoiding Recurrent Tunneled Central Catheter Infection.

OBJECTIVES: Tunneled central venous catheter infection (TCVCi) is a common complication that often necessitates removal of the TCVC and replacement by a further TCVC. Theoretically, insertion of an early - cannulation graft (ecAVG) early after TCVC infection is possible but not widely practiced with concerns over safety and infection in the ecAVG. With 8 years of ecAVG experience, the aim of this study was to compare the outcomes following TCVC infection, comparing replacement with TCVC (TCVCr) versus immediate ecAVG (ecAVGr). DESIGN: Retrospective comparison of 2 cohorts, who underwent replacement of an infected TCVC either by an early cannulation graft (n = 18) or by a further central catheter (n = 39). METHODS: Data were abstracted from a prospectively completed electronic patient record and collected on patient demographics, TCVC insertion, duration and infection, including culture proven bacteriaemia and subsequent access interventions. RESULTS: Eighteen of 299 patients identified from 2012 to 2020 had an ecAVG implanted as treatment for a TCVCi. In a 1-year time-period (January 1, 2015-December 31, 2015) out of 222 TCVC inserted, 39 were as a replacement following a TCVCi. No patient with an ecAVGr developed an immediate infection, nor complication from the procedure. The rate of subsequent vascular access infection was significantly more frequent for those with a TCVCr than with an ecAVGr (0.6 vs. 0.1/patient/1000 HD days, P< 0.000). The number of further TCVC required was significantly higher in the TCVCr group (7.1 vs. 0.4/patient/1000 HD days, P= 0.000). CONCLUSIONS: An ecAVG early following a TCVC infection is safe, reduces the incidence of subsequent infectious complications and reduces the number of TCVC required, with a better functional patency.

Evaluation of malignant effusions using MR-based T1 mapping.

Our aim was to investigate the diagnostic yield of rapid T1-mapping for the differentiation of malignant and non-malignant effusions in an ex-vivo set up. T1-mapping was performed with a fast modified Look-Locker inversion-recovery (MOLLI) acquisition and a combined turbo spin-echo and inversion-recovery sequence (TMIX) as reference. A total of 13 titrated albumin-solutions as well as 48 samples (29 ascites/pleural effusions from patients with malignancy; 19 from patients without malignancy) were examined. Samples were classified as malignant-positive histology, malignant-negative histology and non-malignant negative histology. In phantom analysis both mapping techniques correlated with albumin-content (MOLLI: r = - 0.97, TMIX: r = - 0.98). MOLLI T1 relaxation times were shorter in malignancy-positive histology fluids (2237 ± 137 ms) than in malignancy-negative histology fluids (2423 ± 357 ms) as well as than in non-malignant-negative histology fluids (2651 ± 139 ms); post hoc test for all intergroup comparisons: < 0.05. ROC analysis for differentiation between malignant and non-malignant effusions (malignant positive histology vs. all other) showed an (AUC) of 0.89 (95% CI 0.77-0.96). T1 mapping allows for non-invasive differentiation of malignant and non-malignant effusions in an ex-vivo set up.

Quantitative MRI of the liver: Evaluation of extracellular volume fraction and other quantitative parameters in comparison to MR elastography for the assessment of hepatopathy.

BACKGROUND: Chronic liver diseases pose a major health problem worldwide, while common tests for diagnosis and monitoring of diffuse hepatopathy have considerable limitations. Preliminary data on the quantification of hepatic extracellular volume fraction (ECV) with magnetic resonance imaging (MRI) for non-invasive assessment of liver fibrosis are encouraging, with ECV having the potential to overcome several of these constraints. PURPOSE: To clinically evaluate ECV provided by quantitative MRI for assessing the severity of liver disease. MATERIALS AND METHODS: In this prospective study, multiparametric liver MRI, including T1 mapping and magnetic resonance elastography (MRE), was performed in subjects with and without hepatopathy between November 2018 and October 2019. T1, T2, T2*, proton density fat fraction and stiffness were extracted from parametric maps by regions of interest and ECV was calculated from T1 relaxometries. Serum markers of liver disease were obtained by clinical database research. For correlation analysis, Spearman rank correlation was used. ROC analysis of serum markers and quantitative MRI data for discrimination of liver cirrhosis was performed with MRE as reference standard. RESULTS: 109 participants were enrolled (50.7 ± 16.1 years, 61 men). ECV, T1 and MRE correlated significantly with almost all serum markers of liver disease, with ECV showing the strongest associations (up to r = 0.67 with MELD, p < 0.01). ECV and T1 correlated with MRE (0.75 and 0.73, p < 0.01 each). ECV (AUC 0.89, cutoff 32.2%, sensitivity 85%, specificity 87%) and T1 mapping (AUC 0.85, cutoff 592.5 ms, sensitivity 83%, specificity 75%) featured good performances in detection of liver cirrhosis with only ECV performing significantly superior to model of end stage liver disease (MELD), AST/ALT ratio and international normalized ratio (p < 0.01, respectively). CONCLUSION: Quantification of hepatic extracellular volume fraction with MRI is suitable for estimating the severity of liver disease when using MRE as the standard of reference. It represents a promising tool for non-invasive assessment of liver fibrosis and cirrhosis.

Parameters predicting COVID-19-induced myocardial injury and mortality.

Clinical manifestations of COVID-19 affect many organs, including the heart. Cardiovascular disease is a dominant comorbidity and prognostic factors predicting risk for critical courses are highly needed. Moreover, immunomechanisms underlying COVID-induced myocardial damage are poorly understood. OBJECTIVE: To elucidate prognostic markers to identify patients at risk. RESULTS: Only patients with pericardial effusion (PE) developed a severe disease course, and those who died could be identified by a high CD8/Treg/monocyte ratio. Ten out of 19 COVID-19 patients presented with PE, 7 (78%) of these had elevated APACHE-II mortality risk-score, requiring mechanical ventilation. At admission, PE patients showed signs of systemic and cardiac inflammation in NMR and impaired cardiac function as detected by transthoracic echocardiography (TTE), whereas parameters of myocardial injury e.g. high sensitive troponin-t (hs-TnT) were not yet increased. During the course of disease, hs-TnT rose in 8 of the PE-patients above 16 ng/l, 7 had to undergo ventilatory therapy and 4 of them died. FACS at admission showed in PE patients elevated frequencies of CD3+CD8+ T cells among all CD3+ T-cells, and lower frequencies of Tregs and CD14+HLA-DR+-monocytes. A high CD8/Treg/monocyte ratio predicted a severe disease course in PE patients, and was associated with high serum levels of antiviral cytokines. By contrast, patients without PE and PE patients with a low CD8/Treg/monocyte ratio neither had to be intubated, nor died. CONCLUSIONS: PE predicts cardiac injury in COVID-19 patients. Therefore, TTE should be performed at admission. Immunological parameters for dysfunctional antiviral immunity, such as the CD8/Treg/monocyte ratio used here, supports risk assessment by predicting poor prognosis.

Meningitis recurrente por defectos anatómicos: la bacteria indica su origen / Recurrent meningitis due to anatomical defects: The bacteria indicates its origin

Introducción: La meningitis recurrente es una patología infrecuente. Los factores predisponentes son alteraciones anatómicas o situaciones de inmunodeficiencia. Presentamos 4 casos en los que, excluida una inmunodeficiencia, el microorganismo responsable orientó al defecto anatómico causante de las recurrencias. Pacientes y métodos: Revisión retrospectiva de 4 casos clínicos con diagnóstico de meningitis bacteriana recurrente. Resultados: Caso 1: niño de 30 meses con hipoacusia unilateral, diagnosticado por resonancia magnética (RM) de malformación de Mondini tras 2 episodios de meningitis por Haemophilus influenzae. Reparación quirúrgica tras tercera recurrencia. Caso 2: niña de 14 años diagnosticada por RM de defecto de lámina cribiforme posterior a 3 episodios de meningitis por Streptococcus pneumoniae. Se coloca válvula de derivación ventrículo-peritoneal. Caso 3: niña con meningitis por Staphylococcus aureus a los 2 y 7 meses. La RM muestra seno dérmico occipital que requiere exéresis. Complicación con abscesos cerebelosos por coexistencia de quiste dermoide. Caso 4: niño con meningitis por Streptococcus bovis a los 9 días y porEnterococcus faecium, Klebsiella pneumoniae y Escherichia coli a los 7 meses, con crecimiento de Citrobacter freundii y E. faecium posteriormente. RM compatible con síndrome de Currarino. Incluye fístula rectal de LCR, que se repara quirúrgicamente. A los 4 pacientes se les habían realizado pruebas de imagen durante los primeros episodios de meningitis, informadas como normales. Conclusiones: En los pacientes con meningitis recurrentes se debe valorar la posibilidad de un defecto anatómico; el microorganismo aislado debe ayudar a localizarlo. Es imprescindible conocer la flora normal de los potenciales focos. El tratamiento definitivo es habitualmente quirúrgico (AU)

Introduction: Recurrent meningitis is a rare disease. Anatomical abnormalities and immunodeficiency states are predisposing factors. Four cases, in which immunodeficiency was excluded, are presented. The causal microorganism led to the detection of the anatomical defect responsible for the recurrences. Patients and methods: Retrospective review of 4 cases with clinical diagnosis of recurrent bacterial meningitis. Results: Case 1: a thirty month-old boy with unilateral hearing loss, diagnosed with Mondini abnormality by magnetic resonance imaging (MRI) after 2 episodes of Haemophilus influenzae meningitis. Surgical repair after third recurrence. Case 2: fourteen year-old girl diagnosed by MRI with cribriform plate defect after 3 episodes of meningitis due toStreptococcus pneumoniae. Ventriculoperitoneal shunt was placed. Case 3: girl with meningitis due to Staphylococcus aureus at 2 and 7 months. MRI shows occipital dermal sinus requiring excision. Complication with cerebellar abscesses because of a coexisting dermoid cyst. Case 4: child with meningitis due to Streptococcus bovis at 9 days andEnterococcus faecium, Klebsiella pneumoniae and Escherichia coli at 7 months, with positive cultures to Citrobacter freundii and E. faecium later on. Spinal MRI led to the diagnosis of Currarino syndrome with CSF fistula, which was surgically repaired. The 4 patients had undergone image studies reported as normal during the first episodes. Conclusions: In patients with recurrent meningitis the possibility of an anatomical defect should be considered. The isolated microorganism should help to locate it. It is essential to know the normal flora of the different anatomical sites. The definitive treatment is usually surgical (AU)

[Recurrent meningitis due to anatomical defects: The bacteria indicates its origin]. / Meningitis recurrente por defectos anatómicos: la bacteria indica su origen.

INTRODUCTION: Recurrent meningitis is a rare disease. Anatomical abnormalities and immunodeficiency states are predisposing factors. Four cases, in which immunodeficiency was excluded, are presented. The causal microorganism led to the detection of the anatomical defect responsible for the recurrences. PATIENTS AND METHODS: Retrospective review of 4 cases with clinical diagnosis of recurrent bacterial meningitis. RESULTS: Case 1: a thirty month-old boy with unilateral hearing loss, diagnosed with Mondini abnormality by magnetic resonance imaging (MRI) after 2 episodes of Haemophilus influenzae meningitis. Surgical repair after third recurrence. Case 2: fourteen year-old girl diagnosed by MRI with cribriform plate defect after 3 episodes of meningitis due to Streptococcus pneumoniae. Ventriculoperitoneal shunt was placed. Case 3: girl with meningitis due to Staphylococcus aureus at 2 and 7 months. MRI shows occipital dermal sinus requiring excision. Complication with cerebellar abscesses because of a coexisting dermoid cyst. Case 4: child with meningitis due to Streptococcus bovis at 9 days and Enterococcus faecium, Klebsiella pneumoniae and Escherichia coli at 7 months, with positive cultures to Citrobacter freundii and E. faecium later on. Spinal MRI led to the diagnosis of Currarino syndrome with CSF fistula, which was surgically repaired. The 4 patients had undergone image studies reported as normal during the first episodes. CONCLUSIONS: In patients with recurrent meningitis the possibility of an anatomical defect should be considered. The isolated microorganism should help to locate it. It is essential to know the normal flora of the different anatomical sites. The definitive treatment is usually surgical.

Probiotic helminth administration in relapsing-remitting multiple sclerosis: a phase 1 study.

BACKGROUND: Probiotic treatment strategy based on the hygiene hypothesis, such as administration of ova from the non-pathogenic helminth, Trichuris suis, (TSO) has proven safe and effective in autoimmune inflammatory bowel disease. OBJECTIVE: To study the safety and effects of TSO in a second autoimmune disease, multiple sclerosis (MS), we conducted the phase 1 Helminth-induced Immunomodulatory Therapy (HINT 1) study. METHODS: Five subjects with newly diagnosed, treatment-naive relapsing-remitting multiple sclerosis (RRMS) were given 2500 TSO orally every 2 weeks for 3 months in a baseline versus treatment control exploratory trial. RESULTS: The mean number of new gadolinium-enhancing magnetic resonance imaging (MRI) lesions (n-Gd+) fell from 6.6 at baseline to 2.0 at the end of TSO administration, and 2 months after TSO was discontinued, the mean number of n-Gd+ rose to 5.8. No significant adverse effects were observed. In preliminary immunological investigations, increases in the serum level of the cytokines IL-4 and IL-10 were noted in four of the five subjects. CONCLUSION: TSO was well tolerated in the first human study of this novel probiotic in RRMS, and favorable trends were observed in exploratory MRI and immunological assessments. Further investigations will be required to fully explore the safety, effects, and mechanism of action of this immunomodulatory treatment.

[The effect of captopril and enalapril on the cerebral circulation of normotensive rats]. / Vliianie kaptoprila i énalaprila na mozgovoe krovoobrashchenie normotenzivnykh krys.

Kaptopril and enalapril caused a stable decrease of arterial pressure and resistance of cerebral vessels in experiments on narcotized rats with artificial ventilation of the lungs. No significant changes occurred in the flow of blood in the brain because the drug under study potentiated autoregulatory reactions of the cerebral vessels in response to the decrease in arterial pressure.