Risk Factors for Infectious Complications following Endoscopic Retrograde Cholangiopancreatography in Liver Transplant Patients: A Single-Center Study

Background: Liver transplant recipients often require endoscopic retrograde cholangiopancreatography (ERCP) for biliary complications, which can lead to infections. This retrospective single-center study aimed to identify risk factors for infectious complications following ERCP in liver transplant patients. Methods: A retrospective analysis was conducted on 285 elective ERCP interventions performed in 88 liver transplant patients at a tertiary care center. The primary endpoint was the occurrence of an infection following ERCP. Univariable and multivariable regression analyses, Cox regression, and log-rank tests were employed to assess the influence of various factors on the incidence of infectious complications. Results: Among the 285 ERCP interventions, isolated anastomotic stenosis was found in 175 cases, ischemic type biliary lesion (ITBL) in 103 cases, and choledocholithiasis in seven cases. Bile duct interventions were performed in 96.9% of all ERCPs. Infections after ERCP occurred in 46 cases (16.1%). Independent risk factors for infection included male sex (OR 24.19), prednisolone therapy (OR 4.5), ITBL (OR 4.51), sphincterotomy (OR 2.44), cholangioscopy (OR 3.22), dilatation therapy of the bile ducts (OR 9.48), and delayed prophylactic antibiotic therapy (>1 h after ERCP) (OR 2.93). Additionally, infections following previous ERCP interventions were associated with an increased incidence of infections following future ERCP interventions (p < 0.0001). Conclusion: In liver transplant patients undergoing ERCP, male sex, prednisolone therapy, and complex bile duct interventions independently raised infection risks. Delayed antibiotic treatment further increased this risk. Patients with ITBL were notably susceptible due to incomplete drainage. Additionally, a history of post-ERCP infections signaled higher future risks, necessitating close monitoring and timely antibiotic prophylaxis.

Humoral Immunity in Immunosuppressed IBD Patients after the Third SARS-CoV-2 Vaccination: A Comparison with Healthy Control Subjects

INTRODUCTION

The COVID-19 pandemic is a result of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Vaccination against COVID-19 is crucial for preventing severe illness and controlling the pandemic. This study aimed to examine how immunosuppressed patients with inflammatory bowel disease (IBD) responded to the third mRNA vaccination against SARS-CoV-2. The patients were undergoing treatments such as anti-TNF (infliximab, adalimumab), anti-α4ß7 integrin (vedolizumab), anti-IL12/23 (ustekinumab) and azathioprine (purine analog). Their responses were compared to those of healthy individuals.

METHODS

In this prospective study, 81 IBD patients and 15 healthy controls were enrolled 2-4 months after receiving the third mRNA vaccination. This study measured IgG antibody levels against the SARS-CoV-2 spike protein's receptor binding domain (RBD) and assessed potential neutralization capacity using a surrogate virus neutralization test (sVNT).

RESULTS

Overall, immunosuppressed IBD patients (without SARS-CoV-2 infection) exhibited significantly lower levels of anti-S-IgG (anti-RBD-IgG) and binding inhibition in the sVNT after the third vaccination compared to healthy controls. Patients under anti-TNF therapy showed notably reduced anti-S-IgG levels after the booster vaccination, in contrast to those receiving ustekinumab and azathioprine (p = 0.030, p = 0.031). IBD patients on anti-TNF therapy demonstrated significantly increased anti-S-IgG levels following prior SARS-CoV-2 infection (p = 0.020).

CONCLUSION

Even after the third vaccination, immunosuppressed IBD patients exhibited diminished humoral immunity compared to healthy controls, especially those on anti-TNF therapy. Cases of penetrating infections led to considerably higher antibody levels in IBD patients under anti-TNF therapy compared to uninfected patients. Further investigation through prospective studies in immunosuppressed IBD patients is needed to determine whether this effectively safeguards against future infections or severe disease.

Vitamin A Plasma Levels in COVID-19 Patients: A Prospective Multicenter Study and Hypothesis

COVID-19 is a pandemic disease that causes severe pulmonary damage and hyperinflammation. Vitamin A is a crucial factor in the development of immune functions and is known to be reduced in cases of acute inflammation. This prospective, multicenter observational cross-sectional study analyzed vitamin A plasma levels in SARS-CoV-2 infected individuals, and 40 hospitalized patients were included. Of these, 22 developed critical disease (Acute Respiratory Distress Syndrome [ARDS]/Extracorporeal membrane oxygenation [ECMO]), 9 developed severe disease (oxygen supplementation), and 9 developed moderate disease (no oxygen supplementation). A total of 47 age-matched convalescent persons that had been earlier infected with SARS-CoV-2 were included as the control group. Vitamin A plasma levels were determined by high-performance liquid chromatography. Reduced vitamin A plasma levels correlated significantly with increased levels of inflammatory markers (CRP, ferritin) and with markers of acute SARS-CoV-2 infection (reduced lymphocyte count, LDH). Vitamin A levels were significantly lower in hospitalized patients than in convalescent persons (p < 0.01). Of the hospitalized patients, those who were critically ill showed significantly lower vitamin A levels than those who were moderately ill (p < 0.05). Vitamin A plasma levels below 0.2 mg/L were significantly associated with the development of ARDS (OR = 5.54 [1.01–30.26]; p = 0.048) and mortality (OR 5.21 [1.06–25.5], p = 0.042). Taken together, we conclude that vitamin A plasma levels in COVID-19 patients are reduced during acute inflammation and that severely reduced plasma levels of vitamin A are significantly associated with ARDS and mortality.

Serum levels of ferritin and transferrin serve as prognostic factors for mortality and survival in patients with end-stage liver disease: A propensity score-matched cohort study

BACKGROUND

Patients with end-stage liver disease are known to suffer from a significantly high risk of mortality, but accurate prediction of the course of disease is challenging.

OBJECTIVE

The study aim was to evaluate the independent prognostic and clinical importance of serum levels of ferritin and transferrin for 90-day survival of patients with liver disease.

METHODS

Patients with end-stage liver disease treated during a 2-year period were enrolled retrospectively in a single-centre study. Unmatched and propensity score matching (PSM) analyses were applied.

RESULTS

The study cohort comprised 286 patients with end-stage liver disease, of which 22.9% died during the observational period. High serum ferritin levels and low serum transferrin levels were associated significantly with increased 90-day mortality in the unmatched (p < 0.001) and PSM study population (p = 0.017). Serum levels of ferritin and transferrin had high prognostic capability to predict 90-day survival similar to the Model for End-stage Liver Disease. Patients with serum ferritin values >1030.5 µg/l had a 50% risk of dying within 11 days after measurement, which translated up to a 90-day mortality of 83%.

CONCLUSION

Serum levels of ferritin and transferrin have independent and excellent capabilities to determine prognosis in patients with end-stage liver disease. Ferritin measurements can reliably identify those with high mortality in daily practice.

Effects of flaxseed supplementation on milk production, milk fatty acid composition and nutrient utilization by lactating dairy cows

Twelve multiparous Holstein cows at 72 +/- 20 days in milk were used in a switch-back design with 14-d periods to determine the effect of replacing barley grain into a dairy total mixed ration with micronized or raw flaxseed on nutrient digestibility, milk yield, milk composition. Total mixed diets were (DM basis) 50% barley silage, 50% concentrate mix mainly rolled barley grain and canola meal. Diets were supplemented with 1 kg raw (RF) or micronized (MF) flaxseed to substitute 1 kg of rolled barley grain (C). Neutral detergent fibre, ADF and CP digestibility of the diets were not significantly affected by supplementation; however, calcium digestibility was reduced by 62% and 46% when raw and micronized flax were fed, respectively. Milk yield (38.3, 39.6, and 38.4 kg/d for diets C, RF and MF, respectively) was similar for all diets. Milk fat (3.50, 3.48, and 3.52%) and protein (3.31, 3.34, and 3.31%) for diets C, RF and MF, respectively, were not affected by treatment diets. Concentrations of c9, t11 conjugated linoleic acid (CLA; 0.51, 0.72 and 0.76 g/100 g fatty acids) in milk fat increased (P<0.05) similarly among the two flaxseed supplemented diets. The RF and MF diets significantly increased the C18:1, C18:1 trans-11, C18:2 cis-9, cis-12 and C18:3 in milk fat however, C12:0, C14:0 and C16:0 were significantly reduced compared with control. Replacing barley grain with flaxseed in the diet of lactating cows increased the beneficial fatty acids in milk without depressing nutrient digestibility. Micronization of flaxseed did not reveal any advantage over raw flaxseed.

KATP channels mediate adenosine-induced hyperemia in retina

PURPOSE

The authors and others have shown previously that the purine nucleoside adenosine is a potent vasodilator in the retinal microcirculation, mediating increases in retinal blood flow (RBF) in response to several autoregulatory stimuli. The current experiments were undertaken to elucidate the involvement of adenosine triphosphate (ATP)-sensitive potassium (KATP) channels and the adenylate cyclase--cyclic adenosine monophosphate (cAMP) second-messenger system in the transduction of adenosine's hyperemic response.

METHODS

Retinal fluorescein angiograms were videorecorded in isoflurane-anesthetized newborn pigs, and changes in arteriovenous transit times and retinal arteriolar and venular diameters were used to estimate stimulus-induced changes in RBF.

RESULTS

Intravitreal perivascular microsuffusion of 5 nmol and 50 nmol adenosine caused dose-dependent increases in RBF of 79% +/- 4% (P < 0.05; n = 5) and 323% +/- 61% (P < 0.05; n = 5), respectively. The KATP channel antagonist glibenclamide (0.5 nmol and 5 nmol) caused a significant, dose-dependent attenuation of the hyperemic response to 5 nmol adenosine. The specificity of glibenclamide for blocking KATP channels was demonstrated by its ability to block by 94% +/- 6% (P < 0.05; n = 5) the increase in RBF (94% +/- 7%; P < 0.05) elicited by the intravitreal microsuffusion of the KATP channel agonist cromakalim (5 nmol), whereas it had no effect on the 103% +/- 12% increase in RBF (P < 0.05; n = 5) induced by the nitric oxide donor sodium nitroprusside (15 nmol). Adenosine-induced hyperemia was not potentiated by forskolin (1.7 nmol; n = 4), an adenylate cyclase activator, and was not attenuated by dideoxyadenosine (5 nmol; n = 4), an adenylate cyclase inhibitor. In addition, no significant increases in RBF could be elicited by 2.5 to 25 nmol 8-bromo-cAMP (n = 4), a membrane-permeable cAMP analog.

CONCLUSIONS

These results in the piglet indicate that adenosine increases blood flow in the retina by activating KATP channels, not by increasing in cyclic AMP secondary to adenylate cyclase activation. They also underscore the potential importance of KATP channels in the transduction of retinal vasodilatative responses to other agonists.

Transition strategies: moving systems from old to new

Healthcare institutions today are finding their information systems inadequate. Providers want systems that integrate clinical and financial information as well as support strategic decision making. To support these needs and wants, more organizations are investing in new and more technologically advanced information systems. By looking at three separate scenarios that present circumstances which are common to healthcare organizations, this article presents guidelines that enable an institution to assess its current information systems and discusses options available to help organizations make the transition from old systems to new.