Ultrarapid Development of Ruptured Esophageal Varices in a Patient With a History of Heller Myotomy.

Esophageal varices commonly affect cirrhotic patients as a result of elevated portal system resistance. Blood pools within esophageal portosystemic collateral vessels, which can eventually rupture, leading to life-threatening hemorrhage. To prevent this, cirrhotic patients without a history of varices undergo endoscopic surveillance for varices every 2-3 years. We present an unusual case of variceal hemorrhage in a patient who was seen to have no varices on endoscopic evaluation only a month earlier.

The Bern Birth Cohort (BeBiCo) to study the development of the infant intestinal microbiota in a high-resource setting in Switzerland: rationale, design, and methods.

BACKGROUND: Microbiota composition is fundamental to human health with the intestinal microbiota undergoing critical changes within the first two years of life. The developing intestinal microbiota is shaped by maternal seeding, breast milk and its complex constituents, other nutrients, and the environment. Understanding microbiota-dependent pathologies requires a profound understanding of the early development of the healthy infant microbiota. METHODS: Two hundred and fifty healthy pregnant women (≥20 weeks of gestation) from the greater Bern area will be enrolled at Bern University hospital's maternity department. Participants will be followed as mother-baby pairs at delivery, week(s) 1, 2, 6, 10, 14, 24, 36, 48, 96, and at years 5 and 10 after birth. Clinical parameters describing infant growth and development, morbidity, and allergic conditions as well as socio-economic, nutritional, and epidemiological data will be documented. Neuro-developmental outcomes and behavior will be assessed by child behavior checklists at and beyond 2 years of age. Maternal stool, milk, skin and vaginal swabs, infant stool, and skin swabs will be collected at enrolment and at follow-up visits. For the primary outcome, the trajectory of the infant intestinal microbiota will be characterized by 16S and metagenomic sequencing regarding composition, metabolic potential, and stability during the first 2 years of life. Secondary outcomes will assess the cellular and chemical composition of maternal milk, the impact of nutrition and environment on microbiota development, the maternal microbiome transfer at vaginal or caesarean birth and thereafter on the infant, and correlate parameters of microbiota and maternal milk on infant growth, development, health, and mental well-being. DISCUSSION: The Bern birth cohort study will provide a detailed description and normal ranges of the trajectory of microbiota maturation in a high-resource setting. These data will be compared to data from low-resource settings such as from the Zimbabwe-College of Health-Sciences-Birth-Cohort study. Prospective bio-sampling and data collection will allow studying the association of the microbiota with common childhood conditions concerning allergies, obesity, neuro-developmental outcomes , and behaviour. Trial registration The trial has been registered at www. CLINICALTRIALS: gov , Identifier: NCT04447742.

Direct comparison of echocardiography speckle tracking and cardiac magnetic resonance feature tracking for quantification of right ventricular strain: a prospective intermodality study in functional mitral regurgitation.

BACKGROUND: Functional mitral regurgitation (FMR) is a known risk factor for right ventricular dysfunction (RVDYS). RV global longitudinal strain (GLS) is an emerging index of RV function; however, the magnitude of agreement between RV GLS by echocardiography (echo) and cardiac magnetic resonance (CMR) and the relative utility of each modality for both the diagnosis of RVDYS and prognostication of all-cause mortality and heart failure hospitalization remain unknown. RESULTS: 32% of patients had RVDYS (EF < 50%) on CMR, among whom there was more advanced NYHA class and lower LV and RV ejection fraction (all p < 0.05). RV GLS was impaired in patients with RVDYS whether quantified via STE or FT-CMR, with strong correlation between modalities (r = 0.81). Both STE and FT-CMR derived GLS yielded excellent detection of RVDYS (AUC 0.94 for both), paralleling similar performance for free wall strain by both modalities (FT-CMR AUC 0.94, STE AUC 0.92) with lower accuracy demonstrated by STE derived septal strain (STE AUC 0.78 and FT-CMR AUC 0.92). RV S' and TAPSE showed lower diagnostic accuracy (RV S' AUC 0.77 and TAPSE AUC 0.81). During median follow up of 51 months (IQR 42, 60 months), all-cause mortality or HF hospitalization occurred in 25% (n = 25). Both STE and FT-CMR derived RV GLS stratified risk for adverse prognosis (STE p = 0.007, FT-CMR p = 0.005) whereas conventional RV indices, TAPSE and RV S', did not (TAPSE p = 0.30, S' p = 0.69). CONCLUSION: RV GLS is a robust marker of RVDYS irrespective of modality which provides incremental diagnostic value and improves risk stratification for event free survival beyond conventional RV indices.

Prolonged catheter survival in patients with acute kidney injury on continuous renal replacement therapy using a less thrombogenic micropatterned polymer modification.

BACKGROUND: Continuous renal replacement therapy (CRRT) has been increasingly used in critically ill patients with acute kidney injury (AKI). One of the major properties that likely influence the catheter lifespan includes its surface specificity. We hypothesized that the improvement of blood-surface interaction by a reactive polymer film coating might reduce thrombogenic events in the vascular access device and subsequently lead to prolonged catheter survival in this clinical setting. METHODS: We compared, in a randomized study, the clinical application of two temporary catheters (TCs): one surface-modified double-lumen catheter (smDLC) and one standard sDLC with identical geometry and flow design. Efficacy end points were defined as the ability to complete at least 72 h CRRT without interruption due to TC dysfunction and ability to achieve blood flow rates of ≥150 mL/min. Safety end points were defined as the occurrence of catheter-related (CR) bacteraemia or other CR complications. RESULTS: We evaluated 236 critically ill patients (264 TCs) with AKI on CRRT (continuous venovenous haemodiafiltration) with age (mean±SD) of 56.9±17.9 years. The clinical investigation revealed that the number of hours before TC removal according to clinical requirements was significantly higher with smDLC as compared with sDLC (131±38 vs 113±21 h; P=0.004). Temporary catheter dysfunction occurred in 5% for smDLC and 14% for sDLC; P=0.001. Thrombosis of smDLC and sDLC was observed in 2.3 episodes per 1000 TC-days [95% confidence interval (CI), 1.9-2.5] and 4.2 episodes per 1000 TC-days (95% CI, 4.0-4.4), respectively; P=0.021. The blood flow rate was 221±29 mL/min vs 187±36 mL/min for smDLC and sDLC, respectively; P=0.012. Compared with the overall mean of TC dysfunction or thrombosis, the relative risk of premature removal (<72 h) was 0.43 (95% CI, 0.13-0.98; P=0.041) for smDLC and 2.51 (95% CI, 1.04-9.22; P=0.034) for sDLC with a significantly higher catheter-related bacteraemia rate in this latter group (P=0.008). CONCLUSION: Micropatterned surface coating with a polyurethane polymer significantly increased TC survival with lower dysfunction rate, lower thrombotic events and better bacteriological barrier than sDLC in critically ill patients with AKI necessitating CRRT.

Influence of CD4+/CD25+ regulatory T cells on atherogenesis in patients with end-stage kidney disease.

Atherosclerosis, which is influenced by both traditional and nontraditional cardiovascular risk factors and has been characterized as an inflammatory process, is considered to be the main cause of the elevated cardiovascular risk associated with chronic kidney disease. The inflammatory component of atherosclerosis can be separated into an innate immune response involving monocytes and macrophages that respond to the excessive uptake of lipoproteins and an adaptive immune response that involves antigen-specific T cells. Concurrent with the influx of immune cells to the site of atherosclerotic lesion, the role of the adaptive immune response gradually increases. One of those cells are represented by the CD4+/CD25+ Tregs, which play indispensable roles in the maintenance of natural self-tolerance and negative control of pathological, as well as physiological, immune responses. Altered self-antigens such as oxidized LDLs may induce the development of CD4+/CD25+ Tregs with atheroprotective properties. However, atherosclerosis may be promoted by an imbalance between regulatory and pathogenic immunity that may be represented by the low expression of the forkhead box transcription factor (Foxp3) in CD4+/CD25+ Tregs. Such a defect may break immunologic tolerance and alter both specific and bystander immune suppression, leading to exacerbation of plaque development. Patients with end-stage kidney disease (ESKD) display a cellular immune dysfunction and accelerated atherosclerosis. Uremic solutes that accumulate during ESKD may be involved in these processes. In patients with ESKD and especially in those that are chronically hemodialyzed, oxidative stress induced by oxidized LDLs may increase CD4+/CD25+ Treg sensitivity to Fas-mediated apoptosis as a consequence of specific dysregulation of IL-2 expression. This review will focus on the current state of knowledge regarding the influence of CD4+/CD25+ Tregs on atherogenesis in patients with ESKD, and the potential effect of statins on the circulating number and the functional properties of these cells.