Differences for managing mother’s own milk for very preterm infants across 11 European countries

Background

There is an ongoing debate about the best practices to handle mother's own milk (MOM) for infants born very preterm (VPT, ≤32 weeks of gestation), specifically to prevent the human cytomegalovirus (HCMV) transmission and bacterial contamination of expressed MOM. Thus, we aimed to compare practices for managing MOM for VPT infants in European neonatal intensive care units (NICUs).

Methods

Data were collected as part of the EPICE (Effective Perinatal Intensive Care in Europe) study which explored the use of evidence-based practices for the care of VPT infants in 11 European countries. Structured questionnaires were sent to the head of all participating NICUs with at least 10 VPT admissions. Of the eligible 135 NICUs, 134 replied.

Results

A written protocol for breastfeeding/human milk use was available in 91% of the NICUs. Overall, 34% used human bank milk for all VPT infants whose mothers did not express and 56% reported using fresh MOM without restrictions regarding minimum gestational age, birth weight or risk of HCMV transmission (country range: 0-100%). In 22% of units all VPT infants received MOM pasteurized (country range: 0-73%). HCMV serology on all mothers who express their milk was not required in 71% of units (country range: 7-100%). Among NICUs that performed HCMV serology, 3% provided untreated fresh MOM and 23.5% formula in the case of positive mothers. Systematic bacteriological analyses of MOM were not performed in 76% NICUs (country range: 29-100%) while less than 10% did it for the first milk feeding, 7% every week and 8% with another frequency.

Conclusions

There are large variations in managing MOM across countries, which could reflect differences in regulations or guidelines, and among the same country NICUs, revealing that different options can operate locally. This variability suggests substantial differences in attitudes about what constitutes best practices among European neonatologists.

Key messages

We found significant differences across and within European countries for managing MOM for VPT infants suggesting lack of strong recommendations at the international and national level. There is wide variation in what European neonatologists consider best practices. To guide practice and not jeopardise VPT infants from MOM we need strong evidence-based data.

Facing treatment of non-urothelial bladder cancers in the immunotherapy era

Non-urothelial Bladder Cancer (BC) and variants of urothelial carcinoma account for up to 25 % of all BCs. Given their heterogeneity, these entities are not well represented in clinical trials and treatment remains challenging. Checkpoint inhibitor therapy has shown a role in the treatment of urothelial BC. By contrast, robust evidence regarding its use in other histological types is lacking. We aimed to provide a comprehensive update of non-urothelial and variant urothelial BC, exploring the evidence for immune checkpoint inhibitor therapy. A detailed analysis of the literature was conducted regarding epidemiology, aetiology, diagnosis, prognosis, treatment and outcomes of these patients in the immunotherapy era. A growing body of evidence suggests that immune checkpoint inhibition might have a role to play in non-urothelial BC, similarly to what happened with urothelial carcinomas.

An elevated CA 19-9 is associated with invasive cancer and worse survival in IPMN

BACKGROUND

Current guidelines for IPMN include an elevated serum carbohydrate antigen (CA) 19-9 among the worrisome features. However, the correlation of CA 19-9 with histological malignant features and survival is unclear. Serum CEA is also currently used for preoperative management of IPMN, although its measurement is not evidence-based. Accordingly, we aimed to assess the role of these tumor markers as predictors of malignancy in IPMN.

METHODS

IPMN resected between 1998 and 2018 at Massachusetts General Hospital were analyzed. Clinical, pathological and survival data were collected and compared to preoperative levels of CA 19-9 and CEA. Receiver operating characteristic (ROC) and Cox regression analyses were performed considering cut-offs of 37 U/ml (CA 19-9) and 5 μg/l (CEA).

RESULTS

Analysis of 594 patients showed that preoperative CA 19-9 levels > 37 U/ml (n = 128) were associated with an increased likelihood of invasive carcinoma when compared to normal levels (45.3% vs. 18.0%, P < 0.001), while there was no difference with respect to high-grade dysplasia (32.9% vs 31.9%, P = 0.88). The proportion of concurrent pancreatic cancer was higher in patients with CA 19-9 > 37 U/ml (17.2% vs 4.9%, P < 0.001). An elevated CA 19-9 was also associated with worse overall and disease-free survival (HR = 1.943, P = 0.007 and HR = 2.484, P < 0.001 respectively). CEA levels did not correlate with malignancy.

CONCLUSION

In patients with IPMN, serum CA19-9 > 37 U/ml is associated with invasive IPMN and concurrent pancreatic cancer as well as worse survival, but not with high-grade dysplasia. Serum CEA appears to have minimal utility in the management of these patients.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Multicentre study to establish interpretive criteria for clofazimine drug susceptibility testing

<sec id="st1"> <title>OBJECTIVE</title> To conduct a multicentre study to establish the critical concentration (CC) for clofazimine (CFZ) for drug susceptibility testing (DST) of Mycobacterium tuberculosis on the MGIT™960™ system using the distribution of minimum inhibitory concentrations (MIC) and genotypic analyses of Rv0678 mutations. </sec> <sec id="st2"> <title>DESIGN</title> In phase I of the study, the MIC distribution of laboratory strains (H37Rv and in vitro-selected Rv0678 mutants) and clinical pan-susceptible isolates were determined (n = 70). In phase II, a tentative CC for CFZ (n = 55) was proposed. In phase III, the proposed CC was validated using clinical drug-resistant tuberculosis (DR-TB) isolates stratified by Rv0678 mutation (n = 85). </sec> <sec id="st3"> <title>RESULTS AND CONCLUSION</title> The MIC distribution of CFZ for laboratory and clinical pan-susceptible strains ranged between 0.125 μg/ml and 0.5 μg/ml. As the MIC values of DR-TB isolates used for phase II ranged between 0.25 μg/ml and 1 μg/ml, a CC of 1 μg/ml was proposed. Validation of the CC in phase III showed that probably susceptible and probably resistant Rv0678 mutants overlapped at 1 μg/ml. We therefore recommend a CC of 1 μg/ml, with additional testing at 0.5 μg/ml to define an intermediate category. This was the first comprehensive study to establish a CC for routine phenotypic DST of CFZ using the MGIT960 system to guide therapeutic decisions. </sec>.

P232 A cardiac thrombus... or maybe not

A 61 years old female with history of rheumatic arthritis and Sjogren Syndrom resorted to the emergency room in December of 2017 for pleuritic chest pain and dyspnea. An angioCT showed a luminal filling defect at the left inferior pulmonary artery with extension to the segmentar vessels. A pulmonary embolism (PE) was diagnosed and the patient was admitted. The study performed, including transthoracic echocardiogram (TTE) was unremarkable. Patient was discharged after 15 days treated with a direct oral anticoagulant. Six months later she returned to the emergency room with the same complaints. A new angioCT showed reduction of the previous luminal filling defects, but a focal defect in the filling of the right atrium (RA) was visualized. A TTE showed a mass (17 mm) at the RA with apparent origin at the superior vena cava. A presumptive diagnostic of atrial thrombus was done and patient started therapy with vitamin K antagonist. Three months later, TTE was repeated and the mass was still present (19 mm). Five months later, the mass was still visualized at TTE (17 mm). A transesophagic echocardiogram confirmed the presence of a RA mass with 30x22 mm of major dimensions, with close relation with the interatrial septum suggestive of a tumor. A cardiac magnetic resonance revealed a RA mass without vascularization. A cardiac gated CT showed at the RA a low density nodular image of 26x22 mm at the axial plan, with an extension of 28 mm, adjacent to the posterior wall of the RA. After contrast administration, some areas did not had significant captation while some did, aspects compatible with a "pseudoenhancement" aspect. A positron tomography showed mild to moderate FDG captation at the RA. Meanwhile, patient was under anticoagulation for 2 years with no regression of the mass. For this reason, patient was oriented to cardiac surgery. The mass was resected and the histology revealed a RA myxoma.

Cardiac masses can be due to tumour, thrombus or vegetation. In this case, the mass was highly considered to be a thrombus due to the presence of multiple risk factors: prothrombotic disease and pulmonary embolism. However, the fact that the mass did not reduce with therapy raised suspicion of other diagnosis. Although rare, myxomas can be found in the RA, and should be included in the differential diagnosis of right-sided intracardiac masses. Although myxomas are histologically benign, potential for embolization and sudden death make surgical resection a priority. Its diagnosis has now increased with the use of echocardiogradiography, and has made it the main modality for the evaluation of myxomas. PE is the most dreaded and devastating complication of right-sided myxoma. In cases of RA myxomas, clinically evident PE events are uncommon. Nevertheless, there have been reports of embolization of thrombi or tumor fragments into the pulmonary vessels in cases of right in approximately 3.2% of myxoma patients.

P644 A not so innocent athlete"s heart

We report the case of a 17 years old athlete who resorted to the emergency service for palpitations and dizziness during exercising. He mentioned two episodes of syncope associated with exercise in the last 6 months. He was tachycardic (200 bpm) and hypotensive (85/56 mmHg). The electrocardiogram showed regular wide complex tachycardia with left bundle branch block morphology with superior axis restored to sinus rhythm after electrical cardioversion. In sinus rhythm, it showed T-wave inversion in V1-V5. Patient was admitted for study. Transthoracic echocardiography demonstrated mild enlargement and dysfunction of the right ventricle (RV) with global hypocontractility (FAC of 29%). The cardiac magnetic resonance (CMR revealed a RV end-diastolic volume indexed to surface body area of 180 mL/m2, global hypocinesia and RV dyssynchrony, subepicardial late enhancement in the distal septum and in the middle segment of the infero-septal wall. The patient underwent genetic study which showed a mutation in the gene that encodes the desmocolin-2 protein (DSC-2) involved in the pathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC). According to the 2010 modified Task Force criteria for this diagnosis, the patient presented 4 major criteria for ARVC (characteristic ventricular tachycardia, repolarization and morphofunctional changes and the presence of pathogenic mutation) and the diagnosis was made. Thus, given the clinical presentation, it was implanted a subcutaneous cardioverter and patient is currently in follow-up at the Cardiology service.

ARVC is present in 1 to 1000-5000 people and is responsible for 20% of all sudden cardiac deaths, especially in athletes. Diagnosis is based on structural, functional, electrophysiological and genetic criteria reflecting underlying histological changes. This case shows and reviews the essential characteristics to the disease recognition and, therefore, to the prevention of its most feared complication: sudden cardiac death.

P1261 A heart with red flags

A 67 years old woman with a previous history of hypertension, atrial fibrillation (AF) and known severe concentric hypertrophy (more pronounced at the interventricular septum) with moderate pulmonary hypertension and diastolic dysfunction of the left ventricle (LV) resorted to the urgency service for weight loss, asthenia and dyspnea for minor efforts. Her physical examination was innocent. Her ECG showed AF and low voltage in limb and precordial leads. Patient was admitted at the Cardiology Department for investigation. A new TTE revealed fast progression of the hypertrophic pattern (IVS 26 mm, and posterior wall 18 mm) with a rest outflow tract gradient of 18 mmHg; free right ventricular wall was also hypertrophied with 12 mm and a type II diastolic dysfunction was present. A complete investigation for ventricular hypertrophy and constitutional syndrome was done. CMR demonstrated preserved biventricular systolic function, LV hypertrophy with septal predominance (24 mm) with elevated myocardial mass indexed to body mass (114 g/m2) and late difuse subendocardial gadolinium enhancement. (99m)Tc -DPD scintigraphy was negative for ATTR; Anderson-Fabry disease was excluded by genetic testing. Blood analysis revealed a normocytic/ normochromic anemia and a disproportional ratio of free light immunoglobulin chains K/λ, with a predominance of lambda chains. β2-microglobulin was also elevated. 24 hours urine analyses were normal. The hypothesis of non-secretor multiple myeloma (MM) with light chain immunoglobulin amyloidosis (AL) was then admitted. The patient underwent bone marrow and salivary gland biopsies which confirmed MM and deposition of amyloid, respectively. The FISH analyses demonstrated a delection of RB1 gene on 13q14.3 sequence and of TP53 on 17p13.1, both associated with a poorly prognosis in MM. The patient was referred for oncology where she is currently undergoing chemotherapy for MM and AL amyloidosis.

Amyloidosis represents a large spectrum of systemic diseases. Heart failure may be its first sign. This case reflects the diagnostic work-up in the presence of a hypertrophic LV pattern as well as the importance of high clinical suspicious and early diagnosis. While AL amyloidosis occurs in isolation, 10% of patients with multiple myeloma develop systemic AL amyloid with cardiac involvement. The distinction between these entities is not only semantic, but has extremely important prognosis and therapeutic considerations.

Psychiatric and physical outcomes of long-term use of lithium in older adults with bipolar disorder and major depressive disorder: A cross-sectional multicenter study

OBJECTIVE

Although lithium is widely used in current practice to treat bipolar disorder (BD) and treatment-resistant major depressive disorder (MDD) among older adults, little is known about its efficacy and tolerability in this population, which is generally excluded from randomized clinical trials. The objective of this study was to evaluate the efficacy and tolerability of long-term use of lithium among older adults with BD and MDD.

METHOD

Data from the Cohort of individuals with Schizophrenia and mood disorders Aged 55 years or more (CSA) were used. Two groups of patients with BD and MDD were compared: those who were currently receiving lithium versus those who were not. The effects of lithium on psychiatric (i.e., depressive symptoms severity, perceived clinical severity, rates of psychiatric admissions in the past-year), geriatric (overall and cognitive functioning) and physical outcomes (i.e., rates of non-psychiatric medical comorbidities and general hospital admissions in the past-year) were evaluated. All analyses were adjusted for age, sex, duration of disorder, diagnosis, smoking status, alcohol use, and use of antipsychotics, antiepileptics or antidepressants.

RESULTS

Among the 281 older participants with BD or MDD, 15.7% were taking lithium for a mean duration of 12.5(SD = 11.6) years. Lithium use was associated with lower intensity of depressive symptoms, reduced perceived clinical global severity and lower benzodiazepine use (all p < 0.05), without being linked to greater rates of medical comorbidities, except for hypothyroidism.

LIMITATIONS

Data were cross-sectional and data on lifetime history of psychotropic medications was not assessed.

CONCLUSION

Our results suggest that long-term lithium use may be efficient and relatively well-tolerated in older adults with BD or treatment-resistant MDD.

Dynamics of clonal and plasmid backgrounds of Enterobacteriaceae producing acquired AmpC in Portuguese clinical settings over time

OBJECTIVES

The objective of this work was to provide detailed molecular data on clinically acquired AmpC (qAmpC)-producing Enterobacteriaceae from two different periods (2002-2008 and 2010-2013) in order to clarify the contribution of clonal and plasmid genetic platforms for the current epidemiological scenario concerning extended-spectrum beta-lactams resistance.

METHODS

We analysed 1246 Enterobacteriaceae non-susceptible to third-generation cephalosporins from two hospitals and one community laboratory between 2010 and 2013. Bacterial identification, antibiotic susceptibility, identification of qAmpC and plasmid-mediated quinolone resistance genes, clonal (pulsed-field gel electrophoresis (PFGE), Multilocus sequence typing (MLST)) and plasmid (S1-/I-CeuI-PFGE, replicon typing, hybridization) analysis were performed by standard methods. Whole-genome sequencing (WGS) was performed in two ST11-Klebsiella pneumoniae isolates harbouring DHA-1.

RESULTS

The occurrence of qAmpC was lower (2.6%) than that observed in a previous survey (7.4%), and varied slightly over time. Isolates produced DHA-1 (53%), CMY-2 (44%) or DHA-6 (3%), but significant epidemiological changes were observed in the two surveys. While DHA-1 persisted in different institutions by selection of a worldwide epidemic IncR plasmid in an ST11 harbouring KL105, CMY-2 rates increased over time linked to IncI1 plasmids (instead of IncK or IncA/C₂) in multiple Escherichia coli clones.

CONCLUSIONS

The higher frequency of DHA-1 qAmpC in these species contrasts with the scenario in most European countries. Furthermore, the different genetic backgrounds associated with either extended-spectrum β-lactamases (ESBLs) or acquired AmpC β-lactamases (qAmpC) in our country might have contributed to their differential expansion.