Emergence of Echinococcus multilocularis in Central Continental Croatia: A Human Case Series and Update on Prevalence in Foxes

Human alveolar echinococcosis (HAE), caused by the metacestode stage of Echinococcus multilocularis, has emerged in many European countries over the last two decades. Here, we report the first data on the new HAE focus with increasing incidence in central Croatia, describe its clinical presentation and outcomes in diagnosed patients, and provide an update on the prevalence and geographic distribution of Echinococcus multilocuaris in red foxes. After the initial case in 2017 from the eastern state border, from 2019 to 2022, five new autochthonous HAE cases were diagnosed, all concentrated in the Bjelovar-Bilogora County (the county incidence in 2019 and 2021: 0.98/10⁵, in 2022: 2.94/10⁵/year; prevalence for 2019-2022: 4.91/10⁵). The age range among four female and two male patients was 37-67 years. The patients' liver lesions varied in size from 3.1 to 15.5 cm (classification range: P2N0M0-P4N1M0), and one patient had dissemination to the lungs. While there were no fatalities, postoperative complications in one patient resulted in liver transplantation. In 2018, the overall prevalence of red foxes was 11.24% (28/249). A new focus on HAE has emerged in central continental Croatia, with the highest regional incidence in Europe. Screening projects among residents and the implementation of veterinary preventive measures following the One Health approach are warranted.

Extracorporeal membrane oxygenation in COVID-19: Results of the Croatian Extracorporeal Membrane Oxygenation Referral Center

At the beginning of the COVID-19 pandemic, the role of extracorporeal membrane oxygenation (ECMO) was uncertain and the outcomes of ECMO-treated patients were unfavorable. During the pandemic, medical community realized that carefully selected patients may benefit from ECMO support. The goal of the study was to present the outcomes of ECMO-treated patients with severe COVID-19 ARDS referred to the respiratory ECMO hub in Croatia and to determine variables that influenced the outcome. Our study included all adult patients with confirmed COVID-19 ARDS that required ECMO treatment, in the period between February 2020 and April 2022. All ECMO circuits were veno-venous with femoro-jugular configuration, with drainage at the femoral site. A total of 112 adult patients with COVID-19 induced ARDS were included in the study. All patients had veno-venous ECMO treatment and 34 survived. Surviving patients were discharged home either from the hospital or from a designated rehabilitation facility. The mortality was associated with the incidence of nosocomial bacteremia, occurrence of heparin induced thrombocytopenia and acute renal failure. In order to reduce the mortality in COVID-19 ECMO patients, the treatment should be started as soon as criteria for ECMO are met. Furthermore, complications of the procedure should be detected as soon as possible. However, despite even the optimal approach, the mortality in COVID-19 ECMO patients will surpass that of non-COVID-19 ARDS ECMO patients, mostly due to poor resolving and long lasting ARDS with longer ECMO runs and ensuing infectious complications.

The Impact of Nonalcoholic Fatty Liver Disease on Severe Community-Acquired Pneumonia Outcomes

Community-acquired pneumonia (CAP) is one of the leading causes of morbidity and mortality, while nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. NAFLD is associated with systemic changes in immune response, possibly linked to CAP severity. However, the impact of NAFLD on CAP outcomes has not been determined. The aim of this study was to evaluate clinical course, complications and outcomes of severe CAP requiring ICU treatment in patients with NAFLD in the pre-COVID-19 era. A retrospective cohort study included 138 consecutively hospitalized adult patients with severe CAP admitted to the ICU during a 4-year period: 80 patients with NAFLD and 58 controls. Patients with NAFLD more frequently presented with ARDS (68.7% vs. 43.1%), and required invasive mechanical ventilation (86.2% vs. 63.8%), respiratory ECMO (50% vs. 24.1%), and continuous renal replacement therapy (62.5% vs. 29.3%). Mortality was significantly higher in the NAFLD group (50% vs. 20.7%), and the time from hospital admission to death was significantly shorter. In survival analysis, NAFLD (HR 2.21, 95%CI 1.03-5.06) was associated with mortality independently of other components of metabolic syndrome. In conclusion, our study identified NAFLD as an independent predictor of mortality in patients with severe CAP.

Extracorporeal membrane oxygenation for the treatment of ARDS in Covid-19 and influenza patients: Does etiology matter?

At the beginning of the COVID 19 pandemic, the outcome of patients treated with ECMO was discouraging. Subsequently, it became clear that a certain group of patients may benefit from ECMO treatment. The primary objective of this study was to compare the outcome of ECMO treatment in COVID-19 and influenza patients referred to a tertiary care center. A total of 119 adult patients required ECMO treatment following ARDS secondary to H1N1 (49) and SARS-CoV-2 (70) in the referral ECMO Center based in Zagreb between October 2009 and October 2021. Our study revealed a significantly higher mortality in COVID-19 patients compared to H1N1 influenza when the onset of ARDS was severe enough to require ECMO support. Based on these results and current knowledge, we argue that ECMO treatment for ARDS in COVID-19 patients is more challenging compared to H1N1 influenza patients. Therefore, referral to the most experienced ECMO centers should be considered. Additionally, patient selection and timing for ECMO treatment play a key role in relation to outcome. Mortality rate in COVID-19 patients requiring ECMO treatment may be used as a reference frame for ECMO centers to ensure best possible care and outcome.

Mid trimester amniotic fluid soluble receptor tunica interna endothelial cell kinase-2 levels and risk for preeclampsia

OBJECTIVES

The purpose of this study was to determine if elevated concentration of soluble receptor tunica interna endothelial cell kinase-2 (Tie-2) in the amniotic fluid represent a risk factor for the subsequent development of preeclampsia (PE).

STUDY DESIGN

Amniotic fluid samples were collected as a part of routine clinical diagnostics from women referred to clinical care due to genetic indications. A total of 12 women with preeclampsia and 26 normotensive pregnant women were included in the study. Mean gestational age at amniocentesis was 17.92 weeks of pregnancy in preeclampsia and 17.88 in control group, respectively. Concentrations of sTie-2 in the amniotic fluid were determined by a standardized enzyme immunoassay.

RESULTS

Median concentration of Tie-2 in the amniotic fluid of PE patients was lower (median 1.109 ng/ml) compared with normotensive pregnant women (median 1.433 ng/Ml) but the difference was not statistically significant (p = 0.2973). Concentration of sTie-2 in the amniotic fluid did not significantly correlate with maternal age, gestational age at amniocentesis or delivery, as well as weight or length at birth. A difference in the gestational age at delivery in PE patients (mean 37.7 weeks) and normotensive pregnant controls (mean 39.8 weeks) was statistically significant (p = 0.0003). Birth weight and length of children delivered by PE women (mean 2863.3 g and 48.3 cm) were significantly lower compared with normal pregnancies (mean 3591.2 g and 51.4 cm, p = 0.0002 and p = 0.006, respectively).

CONCLUSION

Our results suggest that amniotic fluid concentrations of sTie-2 do not predict development of PE and that further studies on biomarkers as predictors of PE should include other angiogenic biological response modifiers.

311. Impact of Non-alcoholic Fatty Liver Disease on Clinical Outcomes in Patients with COVID-19

Background

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease with a prevalence up to 30%. NAFLD is strongly associated with components of metabolic syndrome, already recognized as risk factors for worse outcomes in COVID-19. However, the impact of NAFLD on COVID-19 is not well characterized. The aim of this study was to investigate a possible association between NAFLD and COVID-19 severity and outcomes.

Methods

A prospective observational study included consecutively hospitalized adult patients with severe COVID-19 at the University Hospital for Infectious Diseases in Zagreb, Croatia between March and June 2021. On admission patients were screened for fatty liver by the ultrasound and subsequently diagnosed with NAFLD according to current guidelines. Demographic, clinical and laboratory data was collected and correlated to clinical outcomes.

Results

Of the 112 patients included in the study, 77 (68.7%) had NAFLD (59.7% males; median age of 62, IQR 54-66 years). Except for higher prevalence of obesity in NAFLD group (61.0% vs 17.1%) there were no differences in other comorbidities. NAFLD group had higher inflammatory markers CRP (96, IQR 51-138 vs 59, IQR 29-99mg/L) and IL-6 (129, IQR 44-169 vs 25, IQR 8-56pg/mL). Steatosis stage showed positive correlation with BMI, waist/hip ratio, CRP, PCT, IL-6, AST, ALT, LDH and fibrinogen. Steatosis stage correlated with clinical status at the 7-category scale on admission and at days 7, 14 and 28. Patients with NAFLD had longer duration of hospitalization (9, IQR 6-15 vs 6, IQR 5-11 days, p=0.024), more frequently required noninvasive ventilation or high-flow oxygen (24.7% vs 5.7%, p=0.018) and had higher rate of pulmonary embolism (22.1% vs 5.7%, p=0.024). There was no difference in mortality. The median value for clinical status on the ordinal scale at day 7 was significantly higher in NAFLD group at days 7 and 14, as presented in Fig. 1. Multivariable analysis identified age > 65 (OR 3.6, 95%CI 1.3-10.9), LDH > 350 (OR 8.1, 95%CI 2.7-29.4), NAFLD (OR 3.9, 1.1-20.5) and pulmonary embolism (OR 10.4, 2.7-48.3) associated with adverse outcomes at day 28.

The figure shows the patients’ clinical status as assessed on the seven-category ordinal scale on admission and at day 7, 14 and 28, according to the presence of NAFLD. Categories on the ordinal scale were as follows: 1, discharged or ready for discharge; 2, hospitalization in a non–intensive care unit (ICU) without supplemental oxygen; 3, non–ICU hospitalization with supplemental oxygen; 4, ICU or non–ICU hospitalization with noninvasive ventilation or high-flow oxygen; 5, ICU hospitalization with mechanical ventilation; 6, ICU hospitalization with extracorporeal membrane oxygenation or mechanical ventilation and additional organ support; and 7, death.

Conclusion

Our data suggests that NAFLD is associated with COVID-19 severity and might be linked to adverse outcomes in hospitalized patients.

Disclosures

All Authors: No reported disclosures

Nonalcoholic Fatty Liver Disease-A Novel Risk Factor for Recurrent Clostridioides difficile Infection

Recurrent Clostridioides difficile infections (rCDI) have a substantial impact on healthcare systems, with limited and often expensive therapeutic options. Nonalcoholic fatty liver disease (NAFLD) affects about 25% of the adult population and is associated with metabolic syndrome, changes in gut microbiome and bile acids biosynthesis, all possibly related with rCDI. The aim of this study was to determine whether NAFLD is a risk factor associated with rCDI. A retrospective cohort study included patients ≥ 60 years hospitalized with CDI. The cohort was divided into two groups: those who were and were not readmitted with CDI within 3 months of discharge. Of the 329 patients included, 107 patients (32.5%) experienced rCDI. Patients with rCDI were older, had higher Charlson Age-Comorbidity Index (CACI) and were more frequently hospitalized within 3 months. Except for chronic kidney disease and NAFLD, which were more frequent in the rCDI group, there were no differences in other comorbidities, antibiotic classes used and duration of antimicrobial therapy. Multivariable Cox regression analysis showed that age >75 years, NAFLD, CACI >6, chronic kidney disease, statins and immobility were associated with rCDI. In conclusion, our study identified NAFLD as a possible new host-related risk factor associated with rCDI.

Human Alveolar Echinococcosis, Croatia

Alveolar echinococcosis is a parasitic disease caused by the tapeworm larval stage of Echinococcus multilocularis. This zoonotic disease has not been known to occur in Croatia. We report a confirmed case of human alveolar echinococcosis in a patient in Croatia who had never visited a known E. multilocularis–endemic area.

Treatment of Elderly Patients with Chronic Hepatitis C: A Retrospective Cohort Study

SUMMARY – The prevalence of chronic hepatitis C increases in elderly patients. The aims of this study were to identify the factors associated with hepatocellular carcinoma (HCC) and end-stage liver disease development and to evaluate the efficacy and safety of pegylated interferon (PEG-IFNα) plus ribavirin (RBV) therapy in elderly patients. A retrospective cohort study included all consecutive patients with hepatitis C virus (HCV) infection treated with PEG-IFNα+RBV between 2003 and 2013. Elderly patients had a higher frequency of poor prognostic factors including genotype 1 infection, high fibrosis, and high fibrosis index based on four factors (FIB-4) score. The sustained virologic response (SVR) rate for genotype 1 was significantly lower (35.8% vs. 57.1%), while the frequency of PEG-IFNα (27.2% vs. 7.8%), RBV dose reduction (19.6% vs. 9.7%) and treatment discontinuation (13.0% vs. 4.1%) was significantly higher in elderly patients. However, age was not associated with SVR in multivariate analysis, and comparable SVR rates were achieved when adjusted for fibrosis score (Ishak ≤3: 66.7% vs. 69.8%). During the follow-up, HCC was diagnosed in 18 elderly patients (3 SVR+, 4 SVR- and 9 untreated patients). In conclusion, selected elderly patients can achieve comparable SVR rates as younger patients, but with a higher rate of side effects. Since complications of HCV infection occur more frequently in elderly patients, they should be given priority for antiviral therapy.

Nosocomial blood stream infections in patients treated with venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome

BACKGROUND

The incidence of complication rates in patients treated with venovenous extracorporeal membrane oxygenation (VV ECMO) remains substantial and impacts the results of any future trial dealing with ECMO efficacy. Of these complications blood stream infections (BSI) are less well studied. Our objective was to report influence of BSI in ARDS patients treated with VV ECMO.

METHODS

One-hundred adult patients with ARDS treated with VV ECMO at the tertiary care hospital in Zagreb, Croatia between the October of 2009 and the June of 2016 were prospectively included in the study.

RESULTS

In 35% of patients an episode of the nosocomial BSI during VV ECMO treatment was detected. ECMO duration of more than 250 hours and significant bleeding episode independently increase the possibility of acquiring BSI during an ECMO run (odds ratio 3.189, 95% confidence limits 1.108-9.180 and odds ratio 3.378, 95% confidence limits 1.055-10.869 respectively). BSI occurrence had no effect on mortality.

CONCLUSIONS

Our study found that BSI incidence increases with the duration of an ECMO run and bleeding complications with no effect on hospital mortality. Further studies of BSI in this risk group should address the problem of rapid diagnosis and appropriate antimicrobial therapy in an era of growing multiresistance.

Treatment of chronic hepatitis C in Croatian war veterans: experiences from Croatian reference center for viral hepatitis

Aim

To examine the risk factors, comorbidity, severity of liver disease, treatment course, and outcome in Croatian war veterans with chronic hepatitis C, especially those suffering from posttraumatic stress disorder (PTSD).

Methods

We collected medical records of 170 adult men diagnosed with chronic hepatitis C who started treatment with a combination of pegylated interferon-alpha and ribavirin between January 2003 and June 2009 at the Croatian Reference Centre for Viral Hepatitis.

Results

Participants’ mean age was 43 ± 9 years. Among 170 participants, there were 37 war veterans (22%). The main risk factor in veteran patients were operative procedures with transfusions (46% vs 5% in non-veterans; P < 0.001) and in non-veteran patients intravenous drug use (42.1% vs 13%; P < 0.001). The average duration of infection was longer in war veterans (14.5 ± 3.4 vs 12.2 ± 7.2 years; P = 0.020). The percentage of PTSD comorbidity in the whole group was 11% (18/170) and in the war veterans group 49% (18/37). The prevalence of sustained virological response in patients with PTSD was 50% and in patients without PTSD 56%. Treatment reduction in patients with PTSD (33%) was higher than in patients without PTSD (12%;P = 0.030).

Conclusion

Croatian war veterans are a group with high risk of chronic hepatitis C infection because many of them were wounded during the Croatian War 1991-1995. Considerations about PTSD as a contraindication for interferon treatment are unjustified. If treated, patients with PTSD have an equal chance of achieving sustained virological response as patients without PTSD.

Hypoosmotic swelling test for quality control of sperm prepared for assisted reproduction

This study evaluates the clinical usefulness of one additional parameter for assessment of human sperm cell function in vitro--the hypoosmotic swelling test. The hypoosmotic swelling test evaluated the functional integrity of the sperm plasma membrane. The investigation included a comparison of the hypoosmotic swelling test in samples containing motile and immotile spermatozoa and their correlation with the intrauterine insemination outcome. Motile spermatozoa expressed better membrane characteristics, without any importance of the hypoosmotic conditions. Positive correlation exists between HOS results and the outcome of IUI. This test can be a useful addition to the standard battery of semen analyzing tests.

Sperm morphology and motility in different age populations

A prospective study of 77 semen specimens was conducted by routine examination of patients reporting to our laboratory for sterility problems. Abnormal spermatozoa were found mostly in patients over 40 years of age. The most frequent head abnormality was angulation of head (found in 94% of patients) and the most frequent tail abnormality was bent jail (found in 90% of patients). Immature spermatozoa were noted mostly in patients over 40 years of age. Motile sperm concentration was higher in patients up to 26 years of age. However, there was a remarkable heterogeneity of routine andrological parameters within the examined groups.

Intrauterine insemination as a successful method in the treatment of infertility caused by oligospermia

Intrauterine insemination combined with controlled ovarian hyperstimulation was used in treating couples with infertility problem caused by oligospermia. We reported 85 cases, with sperm number less than 20.0 x 10(6) per insemination sample. We obtained successful insemination with 0.7 x 10(6) motile sperm cells per insemination sample. We were particularly successful in treating severe oligospermia. Most of the pregnancies in our population of patients ended in delivering singletons. In conclusion, infertility caused by oligospermia may be successfully treated using IUI with controlled ovarian stimulation. Our opinion is that the accuracy of IUI timing is critical, especially when severe oligospermia is concerned.

Gonadotropins (FSH and LH) and testosterone in human male serum and seminal plasma

Concentrations of gonadotropins (FSH and LH) and testosterone (T) were measured in male serum and the seminal plasma of normo-, oligo- and azoospermic ejaculates. In addition, T levels were measured in tissue extracts of testis and prostate. The concentrations of FSH were nearly the same in seminal plasma and serum. However LH levels were higher in seminal plasma, while T levels were higher in serum. In azoospermic samples, the gonadotropins showed increased concentrations, while T levels were decreased. The concentrations of all three hormones differed in the seminal plasma of infertile men compared to the control group.

Intrauterine insemination with spermatozoa recovered from the aspirate of artificial spermatocoele

Congenital absence of both vas deferens accounts for approximately 10% of cases of obstructive azoospermia. The purpose of the present study was to develop a treatment protocol for a group of azoospermic patients using surgical implantation of alloplastic spermatocoele to enable repeated sperm cell aspiration. Nine patients with congenital absence of both vas deferens, two with obstructed and one with destroyed vas, underwent surgery for the implantation of an alloplastic spermatocoele. In 10 of the 12 patients, vital spermatozoa were recovered from the aspirate and used for intrauterine insemination of their female partners with induced ovulation, some of whom then conceived.

Hormonal response to LH-RH application in normal women

The postovulatory effects of pharmacological doses of LH-RH on progesterone and LH plasma concentrations have been demonstrated. LH-RH injected on the 16th and 18th day of the menstrual cycle induces the discharge of LH; the second application results in a weaker discharge, indicating that the pituitary stores are exhausted. A LH-RH injection induces a decrease of the plasma progesterone concentration which becomes evident after a delay of 26 hours. A statistically significant correlation between LH and progesterone plasma concentrations was obtained 26 h after the administration of LH-RH.