Fungal infections of the central nervous system and paranasal sinuses in onco-haematologic patients. Epidemiological study reporting the diagnostic-therapeutic approach and outcome in 89 cases

Invasive fungal infections (IFI) of the Central Nervous System (IFI-CNS) and Paranasal Sinuses (IFI-PS) are rare, life-threatening infections in haematologic patients, and their management remains a challenge despite the availability of new diagnostic techniques and novel antifungal agents. In addition, analyses of large cohorts of patients focusing on these rare IFI are still lacking. Between January 2010 and December 2016, 89 consecutive cases of Proven (53) or Probable (36) IFI-CNS (71/89) and IFI-PS (18/89) were collected in 34 haematological centres. The median age was 40 years (range 5-79); acute leukaemia was the most common underlying disease (69%) and 29% of cases received a previous allogeneic stem cell transplant. Aspergillus spp. were the most common pathogens (69%), followed by mucormycetes (22%), Cryptococcus spp. (4%) and Fusarium spp. (2%). The lung was the primary focus of fungal infection (48% of cases). The nervous system biopsy was performed in 10% of IFI-CNS, and a sinus biopsy was performed in 56% of IFI-PS (P = 0.03). The Galactomannan test on cerebrospinal fluid has been performed in 42% of IFI-CNS (30/71), and it was positive in 67%. Eighty-four pts received a first-line antifungal therapy with Amphotericine B in 58% of cases, Voriconazole in 31% and both in 11%. Moreover, 58% of patients received 2 or more lines of therapy and 38% were treated with a combination of 2 or more antifungal drugs. The median duration of antifungal therapy was 60 days (range 5-835). A surgical intervention was performed in 26% of cases but only 10% of IFI-CNS underwent neurosurgical intervention. The overall response rate to antifungal therapy (complete or partial response) was 57%, and 1-year overall survival was 32% without significant differences between IFI-CNS and IFI-PS. The overall mortality was 69% but the IFI attributable mortality was 33%. Mortality of IFI-CNS/PS remains high but, compared to previous historical data, it seems to be reduced probably due to the availability of newer antifungal drugs. The results arising from this large contemporary cohort of cases may allow a more effective diagnostic and therapeutic management of these very rare IFI complications in haematologic patients.

Les polyphénols de l’extrait n-butanol de Crataegus oxyacantha : évaluation de leur pouvoir antioxydant et protecteur vis-à-vis de la toxicité de la doxorubicine

La doxorubicine (DOX) est un médicament utilisé en chimiothérapie anticancéreuse, son utilisation clinique est limitée en raison de plusieurs effets secondaires qui lui ont été attribués, comme la cardiotoxicité, la néphrotoxicité et l’hépatotoxicité. Dans la présente étude, nous avons étudié l’efficacité protectrice de l’extrait n-butanol d’une plante médicinale de la famille des Rosacées (Crataegus oxyacantha) contre la toxicité cardiaque, rénale et hépatique induite par la DOX chez des rats Wistar femelles en utilisant des paramètres biochimiques. Les rats ont été soumis à un traitement oral pré- et postphylactique concomitant par l’extrait n-butanol (100 mg/kg) contre la toxicité induite par injection intrapéritonéale unique de la DOX (150 mg/kg). La néphrotoxicité et l’hépatotoxicité ont été évaluées en mesurant les taux sériques de la créatinine, de l’urée, de l’aspartateaminotransférase (ASAT), de l’alanine-aminotransférase (ALAT) et du lactate-déshydrogénase (LDH). Le profil lipidique a également été mesuré. Le traitement par l’extrait n-butanol a considérablement diminué les taux des marqueurs sériques de la toxicité provoquée par la DOX. Les résultats biochimiques qui ont montré que la DOX a causé des dommages importants au niveau des tissus étudiés ont été inversés par l’extrait n-butanol. Les résultats suggèrent que l’extrait n-butanol atténue les lésions rénales, cardiaques et hépatiques induites par la DOX. Les tests antioxydants in vitro (piégeage du radical 2,2-diphényl-1-picrylhydrazyl et inhibition de la peroxydation lipidique) de l’extrait n-butanol ont révélé qu’il présente un pouvoir antioxydant très important ; ces activités sont fortement corrélées avec les teneurs en flavonoïdes et en phénols totaux.

Gut microbiota trajectory in pediatric patients undergoing hematopoietic SCT

Acute GvHD (aGvHD) is the main complication of hematopoietic SCT (HSCT) during the treatment of hematological disorders. We carried out the first longitudinal study to follow the gut microbiota trajectory, from both the phylogenetic and functional points of view, in pediatric patients undergoing HSCT. Gut microbiota trajectories and short-chain fatty acid production profiles were followed starting from before HSCT and through the 3-4 months after transplant in children developing and not developing aGvHD. According to our findings, HSCT procedures temporarily cause a structural and functional disruption of the gut microbial ecosystem, describing a trajectory of recovery during the following 100 days. The onset of aGvHD is associated with specific gut microbiota signatures both along the course of gut microbiota reconstruction immediately after transplant and, most interestingly, prior to HSCT. Indeed, in pre-HSCT samples, non-aGvHD patients showed higher abundances of propionate-producing Bacteroidetes, highly adaptable microbiome mutualists that showed to persist during the HSCT-induced ecosystem disruption. Our data indicate that structure and temporal dynamics of the gut microbial ecosystem can be a relevant factor for the success of HSCT and opens the perspective to the manipulation of the pre-HSCT gut microbiota configuration to favor mutualistic persisters with immunomodulatory properties in the gut.

The frequency of apneas in very preterm infants is increased after non-acid gastro-esophageal reflux

BACKGROUND

To evaluate whether physical and/or chemical features of gastro-esophageal reflux (GER) influence its relationship with apnea of prematurity (AOP).

METHODS

Fifty-eight preterm newborns (GA ≤ 33 weeks) with recurrent apneas were studied by simultaneous polysomnography and combined impedance and pH monitoring, to analyze whether the correlation between GER and AOP varies according to the acidity, duration and height of GERs.

KEY RESULTS

The frequency of apnea (number apnea/min) occurring after-GER [median (range) 0.07 (0-0.25)] was higher than the one detected in GER-free period [0.06 (0.04-0.13), P = 0.015], and also than the one detected before-GER [0 (0-0.8), P = 0.000]. The frequency of apneas detected in the 30'' after pH-GER [median (range), 0 min(-1) (0-1.09)] was higher than the frequency detected in the 30'' before [0 (0-0.91), P = 0.04]; even more, the frequency of apneas detected after non-acid MII-GER episodes [0 (0-2)] was significantly higher than the one detected before [0 (0-1), P = 0.000], whereas the frequency of apneas detected before acid MII-GER episodes [0 (0-0.67)] did not differ from the one detected after [0 (0-2), P = 0.137]. The frequency of pathological apneas detected in the 30'' after-GER (0 min(-1), range 0-0.55) was higher than the frequency detected before (0, range 0-0.09; P = 0.001). No difference in mean height or in mean duration was found between GERs correlated and those non-correlated to apnea.

CONCLUSIONS & INFERENCES

Non-acid GER is responsible for a variable amount of AOP detected after-GER: this novel finding must be taken into consideration when a therapeutic strategy for this common problem is planned.

Gastro-oesophageal reflux increases the number of apnoeas in very preterm infants

OBJECTIVE

To document the existence of a relationship between apnoea of prematurity (AOP) and gastro-oesophageal reflux (GER) in preterm infants.

SETTING

Neonatal intensive care unit.

PATIENTS

Twenty-six preterm infants (gestational age < or =32 weeks) with recurrent apnoeas.

INTERVENTION

Simultaneous and synchronised recording of polysomnography and pH-impedance monitoring (pH-MII). Polysomnography detects and characterises apnoeas, by recording of breathing movement, nasal airflow, electrocardiogram and pulse oximeter saturation. pH-MII is the state-of-the-art methodology for GER detection in preterm newborns.

MAIN OUTCOME MEASURES

Relationship between AOP and GER, which were considered temporally related if both started within 30 seconds of each other.

RESULTS

One hundred and fifty-four apnoeas out of 1136 were temporally related to GER. The frequency of apnoea during the 1-minute time around the onset of GER was significantly higher than the frequency detected in the GER-free period (p = 0.03). Furthermore, the frequency of apnoea in the 30 seconds after GER (GER-triggered apnoeas) was greater than that detected in the 30 seconds before (p = 0.01). A great inter-individual variability was documented in the proportion of GER-triggered apnoeas. A strong correlation between total number of apnoeas and the difference between apnoeas detected 30 seconds after and before GER was found (p = 0.034).

CONCLUSIONS

Our data show that a variable rate of apnoeas can be triggered by GER in very preterm infants. Further studies are needed to recognise clinical features that identify those patients who are more susceptible to GER-triggered apnoeas.