Late relapse after hematopoietic stem cell transplantation for acute leukemia: a retrospective study by SFGM-TC

Late relapse (LR) after allogeneic hematopoietic stem cell transplantation (AHSCT) for acute leukemia is a rare event (nearly 4.5%) and raises the questions of prognosis and outcome after salvage therapy. We performed a retrospective multicentric study between January 1, 2010, and December 31, 2016, using data from the French national retrospective register ProMISe provided by the SFGM-TC (French Society for Bone Marrow Transplantation and Cellular Therapy). We included patients presenting with LR, defined as a relapse occurring at least 2 years after AHSCT. We used the Cox model to identify prognosis factors associated with LR. During the study period, a total of 7582 AHSCTs were performed in 29 centers, and 33.8% of patients relapsed. Among them, 319 (12.4%) were considered to have LR, representing an incidence of 4.2% for the entire cohort. The full dataset was available for 290 patients, including 250 (86.2%) with acute myeloid leukemia and 40 (13.8%) with acute lymphoid leukemia. The median interval from AHSCT to LR was 38.2 months (interquartile range [IQR], 29.2 to 49.7 months), and 27.2% of the patients had extramedullary involvement at LR (17.2% exclusively and 10% associated with medullary involvement). One-third of the patients had persistent full donor chimerism at LR. Median overall survival (OS) after LR was 19.9 months (IQR, 5.6 to 46.4 months). The most common salvage therapy was induction regimen (55.5%), with complete remission (CR) obtained in 50.7% of cases. Ninety-four patients (38.5%) underwent a second AHSCT, with a median OS of 20.4 months (IQR, 7.1 to 49.1 months). Nonrelapse mortality after second AHSCT was 18.2%. The Cox model identified the following factors as associated with delay of LR: disease status not in first CR at first HSCT (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.04 to 1.64; P = .02) and the use of post-transplantation cyclophosphamide (OR, 2.23; 95% CI, 1.21 to 4.14; P = .01). Chronic GVHD appeared to be a protective factor (OR, .64; 95% CI, .42 to .96; P = .04). The prognosis of LR is better than in early relapse, with a median OS after LR of 19.9 months. Salvage therapy associated with a second AHSCT improves outcome and is feasible, without creating excess toxicity.

Reactive surveillance of suicides during the COVID-19 epidemic in France, 2020- March 2022

Background

Mitigation actions during the COVID-19 pandemic, in particular lockdowns and curfews, may impact mental health and suicide in general populations. We aimed to analyse the evolution in suicide deaths from January 2020 to March 2022 in France.

Methods

Using free-text medical causes in death certificates, we built an algorithm, which aimed to identify suicide deaths. We measured its retrospective performances by comparing suicide deaths identified using the algorithm with deaths which had either an ICD10 code for ‘intentional self-harm’ or for ‘external cause of undetermined intent’ as underlying cause. The number of suicide deaths from January 2020 to November 2021 was then compared with the expected number estimated using a generalized additive model. The analysis was stratified by age group and gender. Analysis from December 2021 to March 2022 was conducted using electronic death certificates only.

Results

The free-text algorithm demonstrated high performances. From January 2020 to November 2021, suicide mortality declined during France's three lockdowns, particularly in men, and remained quite comparable with expected values between and after both of the country's lockdowns. Provisional results based on electronic death certificates suggest that suicide mortality remained stable until March 2022.

Conclusions

Monitoring suicide mortality is possible in France with a 4-month delay; this will be reduced to two days when electronic death certification is fully deployed. This study highlighted the absence of an increase in suicide mortality during France's COVID-19 pandemic, and a substantial decline during lockdowns periods, something already observed in other countries. Further studies are required to explain the factors for this decline.

Key messages

• In the absence of reactive coding of medical causes of deaths, the study proposed an approach to reactively identify suicide based on free-text medical causes from death certificates.

• Our findings provide reassurance that the COVID-19 pandemic has not had a negative impact on the general population in terms of suicide in France from March 2020 to September 2021.

Risk Factors for Mortality Among Children Younger Than Age 5 Years With Severe Diarrhea in Low- and Middle-income Countries: Findings From the World Health Organization-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks

BACKGROUND

Diarrhea is the second leading cause of death in children younger than 5 years of age globally. The burden of diarrheal mortality is concentrated in low-resource settings. Little is known about the risk factors for childhood death from diarrheal disease in low- and middle-income countries.

METHODS

Data from the World Health Organization (WHO)-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks, which are composed of active, sentinel, hospital-based surveillance sites, were analyzed to assess mortality in children <5 years of age who were hospitalized with diarrhea between 2008 and 2018. Case fatality risks were calculated, and multivariable logistic regression was performed to identify risk factors for mortality.

RESULTS

This analysis comprises 234 781 cases, including 1219 deaths, across 57 countries. The overall case fatality risk was found to be 0.5%. Risk factors for death in the multivariable analysis included younger age (for <6 months compared with older ages, odds ratio [OR] = 3.54; 95% confidence interval [CI], 2.81-4.50), female sex (OR = 1.18; 95% CI, 1.06-1.81), presenting with persistent diarrhea (OR = 1.91; 95% CI, 1.01-3.25), no vomiting (OR = 1.13; 95% CI, .98-1.30), severe dehydration (OR = 3.79; 95% CI, 3.01-4.83), and being negative for rotavirus on an enzyme-linked immunosorbent assay test (OR = 2.29; 95% CI, 1.92-2.74). Cases from the African Region had the highest odds of death compared with other WHO regions (OR = 130.62 comparing the African Region with the European Region; 95% CI, 55.72-422.73), whereas cases from the European Region had the lowest odds of death.

CONCLUSIONS

Our findings support known risk factors for childhood diarrheal mortality and highlight the need for interventions to address dehydration and rotavirus-negative diarrheal infections.

Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: experience at an epilepsy centre

OBJECTIVE

Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE.

MATERIAL AND METHODS

In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure.

RESULTS

The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages.

CONCLUSION

SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.

Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: Experience at an epilepsy centre

OBJECTIVE

Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE.

MATERIAL AND METHODS

In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure.

RESULTS

The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages.

CONCLUSION

SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.

Gamma Knife® stereotactic radiosurgery as a treatment for essential and parkinsonian tremor: long-term experience

INTRODUCTION

Unilateral Gamma Knife™ stereotactic radiosurgery on the ventral-intermediate nucleus of the thalamus is a minimally invasive neurosurgical option for refractory tremor. We describe the experience of Gamma Knife™ thalamotomy (GKT) in patients with essential tremor (ET) and tremor-dominant Parkinson's disease (PD) at our specialised stereotactic neurosurgery unit.

METHODS

We reviewed the cases of patients treated with GKT between January 2014 and February 2018 with a minimum of 12 months' follow-up. We analysed clinical and demographic variables, indication, radiation dose, effectiveness (based on subscales of the Fahn-Tolosa-Marin [FTM] scale and the Movement Disorders Society-Unified Parkinson's Disease Rating Scale [MDS-UPDRS] motor score), and adverse events.

RESULTS

Thirteen patients were registered, 6 with a diagnosis of tremor-dominant PD, four with refractory ET, and three with ET and PD. Median age was 78 years (range, 62-83), with seven patients aged over 75 years. Four patients were receiving anticoagulants and two had history of stroke. The maximum radiation dose administered was 130 Gy. Mean (standard deviation) follow-up duration was 30.0 (14.5) months. Significant tremor improvement was observed on the FTM subscales: 63.6% at 12 months and 63.5% at the end of follow-up; MDS-UPDRS tremor items showed improvements of 71.3% at 12 months and 60.3% at the end of follow up. Eleven patients reported significant improvements in quality of life, and 3 reported mild and transient adverse effects.

CONCLUSIONS

This is the largest series of patients with essential and parkinsonian tremor treated with GKT and followed up in the long term in Spain. GKT can be safe and effective in the long term in patients with refractory tremor, including in elderly patients and those receiving anticoagulants.

Gamma Knife® stereotactic radiosurgery as a treatment for essential and parkinsonian tremor: long-term experience

INTRODUCTION

Unilateral Gamma Knife™ stereotactic radiosurgery on the ventral-intermediate nucleus of the thalamus is a minimally invasive neurosurgical option for refractory tremor. We describe the experience of Gamma Knife™ thalamotomy (GKT) in patients with essential tremor (ET) and tremor-dominant Parkinson's disease (PD) at our specialised stereotactic neurosurgery unit.

METHODS

We reviewed the cases of patients treated with GKT between January 2014 and February 2018 with a minimum of 12 months' follow-up. We analysed clinical and demographic variables, indication, radiation dose, effectiveness (based on subscales of the Fahn-Tolosa-Marin [FTM] scale and the Movement Disorders Society-Unified Parkinson's Disease Rating Scale [MDS-UPDRS] motor score), and adverse events.

RESULTS

Thirteen patients were registered, 6 with a diagnosis of tremor-dominant PD, four with refractory ET, and three with ET and PD. Median age was 78 years (range, 62-83), with seven patients aged over 75 years. Four patients were receiving anticoagulants and two had history of stroke. The maximum radiation dose administered was 130 Gy. Mean (standard deviation) follow-up duration was 30.0 (14.5) months. Significant tremor improvement was observed on the FTM subscales: 63.6% at 12 months and 63.5% at the end of follow-up; MDS-UPDRS tremor items showed improvements of 71.3% at 12 months and 60.3% at the end of follow up. Eleven patients reported significant improvements in quality of life, and 3 reported mild and transient adverse effects.

CONCLUSIONS

This is the largest series of patients with essential and parkinsonian tremor treated with GKT and followed up in the long term in Spain. GKT can be safe and effective in the long term in patients with refractory tremor, including in elderly patients and those receiving anticoagulants.

Contacts with health services during the year prior to suicide death in France (2013-2015)

Background

This study was designed to describe contacts with health services during the year before suicide death in France, and to compare the prevalent mental and physical conditions in these people to those of the general population.

Methods

Data were extracted from the French National Health Data System (SNDS), which comprises comprehensive claims data for inpatient and outpatient care linked to the national causes-of-death registry. Individuals, national health insurance general scheme beneficiaries (i.e. 76% of the population living in France), aged 15 years or older, who died from suicide in France in 2013-2015 were included. Medical consultations, emergency room visits, and hospitalisations during the year preceding death were collected. Conditions were identified, and standardised prevalence ratios (SPRs) were estimated to compare prevalence rates in suicide decedents with those of the general population.

Results

The study included 19,144 suicide decedents. Overall, 8.5% of suicide decedents consulted a physician or attended an emergency room on the day of death, 34.1% during the week before death, 60.9% during the month before death. Most contacts involved a general practitioner or an emergency room (46.2% of suicide decedents consulted a general practitioner during the month before death, 16.7% attended an emergency room). During the month preceding suicide, 24.4% of individuals were hospitalised at least once. Mental conditions (36.8% of cases) were 7.9-fold (SPR 95% CI: 7.7-8.1) more prevalent in suicide decedents than in the general population. The highest SPRs among physical conditions were for liver/pancreatic diseases (SPR=3.3, 95% CI: 3.1-3.6) and epilepsy (SPR=2.7, 95% CI: 2.4-3.0).

Conclusions

General practitioners and emergency departments have frequent contacts with suicide decedents during the last weeks before death and are at the forefront of suicide risk identification and prevention in individuals with mental, but also physical conditions.

Key messages

Mental and physical conditions are more common among suicide decedents than in the general population, and contacts with primary care services are frequent in the last weeks prior to suicide. Primary care services (general practitioners and emergency rooms) should be targeted for suicide preventive interventions.

Update on Immunodeficiency-Associated Vaccine-Derived Polioviruses - Worldwide, July 2018-December 2019

Since establishment of the Global Polio Eradication Initiative* in 1988, polio cases have declined >99.9% worldwide; extensive use of live, attenuated oral poliovirus vaccine (OPV) in routine childhood immunization programs and mass campaigns has led to eradication of two of the three wild poliovirus (WPV) serotypes (types 2 and 3) (1). Despite its safety record, OPV can lead to rare emergence of vaccine-derived polioviruses (VDPVs) when there is prolonged circulation or replication of the vaccine virus. In areas with inadequate OPV coverage, circulating VDPVs (cVDPVs) that have reverted to neurovirulence can cause outbreaks of paralytic polio (2). Immunodeficiency-associated VDPVs (iVDPVs) are isolated from persons with primary immunodeficiency (PID). Infection with iVDPV can progress to paralysis or death of patients with PID, and excretion risks seeding cVDPV outbreaks; both risks might be reduced through antiviral treatment, which is currently under development. This report updates previous reports and includes details of iVDPV cases detected during July 2018-December 2019 (3). During this time, 16 new iVDPV cases were reported from five countries (Argentina, Egypt, Iran, Philippines, and Tunisia). Alongside acute flaccid paralysis (AFP) surveillance (4), surveillance for poliovirus infections among patients with PID has identified an increased number of persons excreting iVDPVs (5). Expansion of PID surveillance will facilitate early detection and follow-up of iVDPV excretion among patients with PID to mitigate the risk for iVDPV spread. This will be critical to help identify all poliovirus excretors and thus achieve and maintain eradication of all polioviruses.

Resting-state functional connectivity of emotion regulation networks in euthymic and non-euthymic bipolar disorder patients

Background

Previous functional magnetic resonance imaging studies in bipolar disorder (BD) have evidenced changes in functional connectivity (FC) in brain areas associated with emotion processing, but how these changes vary with mood state and specific clinical symptoms is not fully understood.

Methods

We investigated resting-state FC between a priori regions of interest (ROIs) from the default-mode network and key structures for emotion processing and regulation in 27 BD patients and 27 matched healthy controls. We further compared connectivity patterns in subgroups of 15 euthymic and 12 non-euthymic patients and tested for correlations of the connectivity strength with measures of mood, anxiety, and rumination tendency. No correction for multiple comparisons was applied given the small population sample and pre-defined target ROIs.

Results

Overall, regardless of mood state, BD patients exhibited increased FC of the left amygdala with left sgACC and PCC, relative to controls. In addition, non-euthymic BD patients showed distinctive decrease in FC between right amygdala and sgACC, whereas euthymic patients showed lower FC between PCC and sgACC. Euthymic patients also displayed increased FC between sgACC and right VLPFC. The sgACC–PCC and sgACC–left amygdala connections were modulated by rumination tendency in non-euthymic patients, whereas the sgACC-VLPFC connection was modulated by both the current mood and tendency to ruminate.

Conclusions

Our results suggest that sgACC-amygdala coupling is critically affected during mood episodes, and that FC of sgACC play a pivotal role in mood normalization through its interactions with the VLPFC and PCC. However, these preliminary findings require replication with larger samples of patients.

The use of a new collagen matrix to support the regeneration of peri-implant soft tissue laser-assisted: case report

Several factors compete for both the achievement and the long-term maintenance of osseointegration; among these, of importance is the width and integrity of the peri-implant soft tissue. Many authors already underlined the importance for implant-prosthesis procedures to maintain a good biological seal together with a low bacterial cell surface charge (this is also valid for a natural tooth with an undamaged periodontium). The aim of this work is to present, through a clinical case, a new technique that focuses on the regeneration of soft tissue around a post-extractive implant. For the case reported, a post-extractive implant surgery of an inferior molar of the fourth quadrant with a buccal bone resorption of 3mm in the mesial section of the root, three dimensional collagen matrices (Bioteck) and a blend of equine spongy bone granules (OX Bioteck) were used, combined with aPDT without dye (Rey Protocol). With an easy and not invasive surgery, this technique allows the recreation of new gingiva around the implant.

Chromatin three-dimensional interactions mediate genetic effects on gene expression

Studying the genetic basis of gene expression and chromatin organization is key to characterizing the effect of genetic variability on the function and structure of the human genome. Here we unravel how genetic variation perturbs gene regulation using a dataset combining activity of regulatory elements, gene expression, and genetic variants across 317 individuals and two cell types. We show that variability in regulatory activity is structured at the intra- and interchromosomal levels within 12,583 cis-regulatory domains and 30 trans-regulatory hubs that highly reflect the local (that is, topologically associating domains) and global (that is, open and closed chromatin compartments) nuclear chromatin organization. These structures delimit cell type-specific regulatory networks that control gene expression and coexpression and mediate the genetic effects of cis- and trans-acting regulatory variants on genes.

Cross-cultural Convergent Validation of the Spanish and English Versions of the Personal Impact of Epilepsy Scale (PIES) in a Cohort of Patients from a Level IV Epilepsy Center in South Florida

Objective

To provide further convergent validity on the Personal Impact of Epilepsy Scale (PIES) Spanish version for use in Hispanics with epilepsy.

Participants and Method

This study included 90 patients (22 Hispanic and Spanish speaking - HSS, 30 Hispanic and English speaking – HES, and 38 non-Hispanic and English speaking – NHES) who were diagnosed with epilepsy and referred by their epileptologist for a comprehensive neuropsychological evaluation that, in addition to cognitive measures, also included the Beck Depression Inventory (BDI-II), Beck Anxiety Inventory (BAI), and PIES in English or Spanish- depending on the participant’s primary language. The PIES was created with subscales to measure the effect of seizures, adverse effects of treatment, and comorbidities such as mood disorders on quality of life. We compared scores on the PIES subscales in English and Spanish to determine equivalence. We further examined if language of administration moderated the relationship between PIES subscale scores and depression/anxiety through nonparametric bootstrapping.

Results

There were no significant demographic or clinical differences between the 3 groups examined. ANOVA contrast of mean scores on all PIES subscales between HSS, HES and NHES groups did not reach significance (Seizures F [2,88] = .06 , p = -.93; Medication use F[2,88] = 1.95, p = .14, Comorbidity F[2,88] = .64, p = .52, and total PIES F[2,88] = .19, p = .83). The relationships between PIES and BDI-II/BAI scores were not significantly moderated by language of administration.

Conclusions

Our data suggest clinical equivalency between the English and Spanish versions of the PIES. Furthermore, the relationships between PIES subscales and the BDI-II/BAI were not significantly changed by language of administration. These findings indicate that the Spanish PIES appears to have good convergent validity with the original English version and can be useful in the assessment of quality of life in HSS patients.

Intellectual, Psychological, and Clinical Predictors of Quality of Life in Patients with Epilepsy from a Level IV Epilepsy Center in South Florida

Objective

To examine clinical, cognitive, and psychological predictors of Quality of Life (QOL) among Hispanics and non-Hispanics with epilepsy.

Participants and Method

Data was collected from 90 patients (52 Hispanic; H, 38 Non-Hispanic; NH) diagnosed with epilepsy and referred for neuropsychological evaluation that included measures of depression (BDI-II), anxiety (BAI), and QOL using the Personal Impact of Epilepsy Scale (PIES). We conducted multiple linear regression models with patient’s full-scale IQ, age of seizure onset, duration of seizure disorder, and anxiety and depression symptom severity entered as predictors, with the PIES as outcome measure.

Results

There were no significant differences between H and NH on any demographic or clinical variable except for longer duration of seizure disorder (t = 2.20, p = 0.03) in H. For the complete sample, higher FSIQ predicted better QOL in relation to the perceived disabling effects of seizures (β = .28, p =.02), higher BDI-II scores predicted more negative medication side effects and greater mood related disruption in QOL (β = -2.27, p =.03; β = -3.82, p =.00), and higher BAI scores were the best predictor for worse overall QOL (β = -.29, p = .05). When the sample was divided according to ethnic background, longer seizure duration was associated with the adverse effects of less medication in the H group (β = .32, p =.04), with all other findings being identical to those of the complete sample. When results for NH patients were analyzed, none of the intellectual, psychological and clinical variables were significantly associated with any of the QOL scales; however, the relationship between the BAI and comorbid mood dysfunction approached significance (β = -1.45, p = .059).

Conclusions

Our data indicates that overall QOL was primarily predicted by the severity of anxiety symptoms, but not influenced by overall intelligence, symptoms of depression, and clinical seizure variables.

Risk Factors of Mortality After Liver Transplantation in Uruguay

INTRODUCTION

Identification of predictive factors of mortality in a liver transplant (LT) program optimizes patient selection and allocation of organs.

OBJECTIVE

To determine survival rates and predictive factors of mortality after LT in the National Liver Transplant Program of Uruguay.

METHODS

A retrospective study was conducted analyzing data prospectively collected into a multidisciplinary database. All patients transplanted since the beginning of the program on July 2009 to April 2017 were included (n = 148). Twenty-nine factors were analyzed through the univariate Kaplan-Meier model. A Cox regression model was used in the multivariate analysis to identify the independent prognostic factors for survival.

RESULTS

Overall survival was 92%, 87%, and 78% at discharge, 1 year, and 3 years, respectively. The Kaplan-Meier survival curves were significantly lower in: recipients aged >60 years, Model for End-Stage Liver Disease score >21, LT due to hepatocellular carcinoma (HCC) and acute liver failure (ALF), donors with comorbidities, intraoperative blood loss beyond the median (>2350 mL), red blood cell transfusion requirement beyond the median (>1254 mL), intraoperative complications, delay of extubation, invasive bacterial, and fungal infection after LT and stay in critical care unit >4 days. The Cox regression model (likelihood ratio test, P = 1.976 e^-06) identified the following independent prognostic factors for survival: LT for HCC (hazard ratio [HR] 4.511; P = .001) and ALF (HR 6.346; P = .004), donors with comorbidities (HR 2.354; P = .041), intraoperative complications (HR 2.707; P = .027), and invasive fungal infections (HR 3.281; P = .025).

CONCLUSION

The survival rates of LT patients as well as the mortality-associated factors are similar to those reported in the international literature.

Mortality Analysis of Acute Liver Failure in Uruguay

BACKGROUND

Acute liver failure (ALF) is a syndrome with high mortality.

OBJECTIVE

Describe characteristics and outcomes of patients with ALF in Uruguay, and identify factors associated with mortality.

METHODS

A retrospective analysis of 33 patients with ALF was performed between 2009 and 2017.

RESULTS

The patients' median age was 43 years, and 64% were women. Average Model for End-Stage Liver Disease (MELD) score at admission was 33. The median referral time to the liver transplant (LT) center was 7 days. The most common etiologies were viral hepatitis (27%), indeterminate (21%), autoimmune (18%), and Wilson disease (15%). Overall mortality was 52% (71% of transplanted and 46% of nontransplanted patients). Dead patients had higher referral time (10 vs 4 days, P = .008), higher MELD scores at admission (37 vs 28) and highest achieved MELD scores (42 vs 29; P < .001), and higher encephalopathy grade III to IV (94% vs 25%, P < .001) than survivors. Patients without LT criteria (n = 4) had lower MELD score at admission (25 vs 34, P = .001) and highest achieved MELD score (27 vs 37, P = .008) compared with the others. Patients with LT criteria but contraindications (n = 7) had higher MELD scores at admission (38 vs 31, P = .02), highest achieved MELD scores (41 vs 34, P = .03), and longer referral time (10 days) than those without contraindications (3.5 days) or those without LT criteria (7.5 days, P = .02). Twenty-two patients were listed; LT was performed in 7, with a median time on waiting list of 6 days.

CONCLUSIONS

ALF in Uruguay has high mortality associated with delayed referral to the LT center, MELD score, and encephalopathy. The long waiting times to transplantation might influence mortality.

Etiology of Severe Acute Watery Diarrhea in Children in the Global Rotavirus Surveillance Network Using Quantitative Polymerase Chain Reaction

Background

The etiology of acute watery diarrhea remains poorly characterized, particularly after rotavirus vaccine introduction.

Methods

We performed quantitative polymerase chain reaction for multiple enteropathogens on 878 acute watery diarrheal stools sampled from 14643 episodes captured by surveillance of children <5 years of age during 2013-2014 from 16 countries. We used previously developed models of the association between pathogen quantity and diarrhea to calculate pathogen-specific weighted attributable fractions (AFs).

Results

Rotavirus remained the leading etiology (overall weighted AF, 40.3% [95% confidence interval {CI}, 37.6%-44.3%]), though the AF was substantially lower in the Americas (AF, 12.2 [95% CI, 8.9-15.6]), based on samples from a country with universal rotavirus vaccination. Norovirus GII (AF, 6.2 [95% CI, 2.8-9.2]), Cryptosporidium (AF, 5.8 [95% CI, 4.0-7.6]), Shigella (AF, 4.7 [95% CI, 2.8-6.9]), heat-stable enterotoxin-producing Escherichia coli (ST-ETEC) (AF, 4.2 [95% CI, 2.0-6.1]), and adenovirus 40/41 (AF, 4.2 [95% CI, 2.9-5.5]) were also important. In the Africa Region, the rotavirus AF declined from 54.8% (95% CI, 48.3%-61.5%) in rotavirus vaccine age-ineligible children to 20.0% (95% CI, 12.4%-30.4%) in age-eligible children.

Conclusions

Rotavirus remained the leading etiology of acute watery diarrhea despite a clear impact of rotavirus vaccine introduction. Norovirus GII, Cryptosporidium, Shigella, ST-ETEC, and adenovirus 40/41 were also important. Prospective surveillance can help identify priorities for further reducing the burden of diarrhea.

Photodynamic Therapy (Association Diode Laser/Hydrogen Peroxide): Evaluation of Bactericidal Effects on Periodontopathy Bacteria: An in Vitro Study

The main cause for the development of periodontitis is the accumulation of subgingival microbial deposits organized tightly to the porous surface of the tooth cementuni. The growth of the microbial populations and the immunological reaction of the host organism are responsible for the destruction of periodontal ligament apparatus. The primary goal in the treatment of periodontitis is the complete removal of subgingival bacterial deposits. The large amount of evidence establishing a microbial etiology for periodontitis (has been the basis for the development of antimicrobial treatment approaches. Photodynamic therapy (PDT) employs a non-toxic dye, termed a photosensitizer (PS), and low intensity visible light which, in the presence of oxygen, combine to produce cytotoxic species. In this in vitro protocol study it was tested the bactericidal efficacy of Diode laser (Oralia), of Hydrogen Peroxyde and the association Diode Laser-Peroxyd Hydrogen (PDT) on Prevotella intermedia, Peptostreptococcus micros and Fusobacterium nucleatum, three of the most aggressive bacteria envolved on periodontal disease.

Oxygen high level laser therapy is efficient in treatment of chronic periodontitis: a clinical and microbiological study using PCR analysis

In periodontology, lasers have been suggested for the photodynamic therapy (PDT). Such therapy can be defined as the inactivation of cells, microorganisms or molecules induced by light and not by heat. The aim of our study is to assess the effect of Oxygen high-level laser therapy (OHLLT) in removing all bacterial deposits on root or implant surface by means of mechanical instrumentation and laser irradiation. OHLLT has two effects on targeted bacteria and tissues, decontamination and biostimulation. A total of 33 patients were randomly selected with a diagnosis of chronic periodontitis. The patients enrolled were 16 females and 17 males, six smokers and 4 diabetic patients. For each patient a periodontal charting was performed, assessing probing depth, plaque index and bleeding on probing at baseline and after 6 months. Microbiological analysis were performed with PCR Real Time, using paper tips to withdraw gingival fluid in periodontal pockets before and after treatment, at baseline and after 6 months. All patients were treated with OHLLT at baseline, after 1 week, after 2 weeks and every month for 6 months. After 6 months, all periodontal pockets were treated successfully, without complications and no significant differences in results. All clinical parameters showed an improvement, with a decrease both of plaque index (average decrease of 75%), bleeding on probing (average decrease of 62%) and probing depth (average decrease of 1.8 mm). After the treatment, a remarkable decrease in bacteria amount, both for each species and for total bacteria was observed except for Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis demonstrating that this laser protocol is effective on periodontitis treatment. OHLLT is efficient in treatment of chronic periodontitis as demonstrated by clinical and microbiological parameters, going beyond the traditional periodontal therapy.

Effects of laser biostimulation on the epithelial tissue for keratinized layer differentiation: an in vitro study

Gingival augmentation techniques proposed in the international literature do not exclude a surgical component, which determines consequent post-surgical discomfort and results are not always predictable. In recent years, the introduction of laser biostimulation has led to a less invasive approach, particularly in the treatment of periodontally compromised patients, limiting the surgical phase to seriously compromised cases, with regeneration techniques for the restoration of a correct periodontal tissue anatomy. The aim of this in vitro study is to establish the validity of laser biostimulation in order to develop the epithelial keratinized layer of the tissue by stimulating fibroblasts-keratinocytes organotypic cultures and fibroblasts and keratinocytes mono-cultures. We created two groups (test and control), each one composed of 3 fibroblast cultures, 3 keratinocyte cultures and 3 organotypic cultures. We performed laser irradiation of test group with Wiser Doctor Smile Lambda, Flat Top Handpiece, at 50 J/cm2 of fluency with one application every 40 h for a total of 5 applications. Forty-eight h after the last laser application, we investigated the presence and amount of keratins 5 and 8 with citofluorymetric and western blotting analyses. Analyses showed an increase in keratin synthesis in test group cultures, showing a remarkable increase in production of keratin 8 in co-cultures test. Laser biostimulation can considerably enhance keratin synthesis when applied with high energy doses and repeated applications to keratinocytes-fibroblasts co-cultures.

Interplay between cellular redox oscillations and circadian clocks

The circadian clock is a cellular timekeeping mechanism that helps organisms from bacteria to humans to organize their behaviour and physiology around the solar cycle. Current models for circadian timekeeping incorporate transcriptional/translational feedback loop mechanisms in the predominant model systems. However, recent evidence suggests that non-transcriptional oscillations such as metabolic and redox cycles may play a fundamental role in circadian timekeeping. Peroxiredoxins, an antioxidant protein family, undergo rhythmic oxidation on the circadian time scale in a variety of species, including bacteria, insects and mammals, but also in red blood cells, a naturally occurring, non-transcriptional system. The profound interconnectivity between circadian and redox pathways strongly suggests that a conserved timekeeping mechanism based on redox cycles could be integral to generating circadian rhythms.

The excess mortality related to cardiovascular diseases and cancer among adults pharmacologically treated for diabetes--the 2001-2006 ENTRED cohort

AIMS

To compare the 5-year mortality (overall and cause-specific) of a cohort of adults pharmacologically treated for diabetes with that of the rest of the French adult population.

METHODS

In 2001, 10 000 adults treated for diabetes were randomly selected from the major French National Health Insurance System database. Vital status and causes of death were successfully extracted from the national registry for 9101 persons. We computed standardized mortality ratios.

RESULTS

Over 5 years, 1388 adults pharmacologically treated for diabetes died (15% of the cohort, 32.4/1000 person-years). An excess mortality, which decreased with age, was found for both genders [standardized mortality ratio 1.45 (1.37-1.52)]. Excess mortality was related to: hypertensive disease [2.90 (2.50-3.33)], ischaemic heart disease [2.19 (1.93-2.48)], cerebrovascular disease [1.76 (1.52-2.03)], renal failure [2.14 (1.77-2.56)], hepatic failure [2.17 (1.52-3.00)] in both genders and septicaemia among men [1.56 (1.15-2.09)]. An association was also found with cancer-related mortality: liver cancer in men [3.00 (2.10-4.15)]; pancreatic cancer in women [3.22 (1.94-5.03)]; colon/rectum cancer in both genders [1.66 (1.28-2.12)]. Excess mortality was not observed for breast, lung or stomach cancers.

CONCLUSIONS

Adults pharmacologically treated for diabetes had a 45% increased risk of mortality at 5 years, mostly related to cardiovascular complications, emphasizing the need for further prevention. The increased risk of mortality from cancer raises questions about the relationship between cancer and diabetes and prompts the need for improved cancer screening in people with diabetes.

Ultrasound-guided internal jugular vein catheterization: a randomized controlled trial

INTRODUCTION

Even though advantages of ultrasound line placement seem obvious, many countries do not have easy access to such technology. This study aims to compare the degree of difficulty in central venous line placement with or without ultrasound and the incidence of complications, and to establish the effect of the operator's degree of training.

METHODS

The study included 257 patients that required central venous catheterization during the study period. Patients were divided into groups according to the operator's experience: expert group (over 70 central accesses performed before the study) (n=152) and in-training or non-expert group. Procedures were randomized to "without ultrasound" (n=80 expert and 54 non-expert) and "with ultrasound" (n=72 expert and 51 non-expert).

RESULTS

Catheter placements were more successful in the "expert" and in the "with ultrasound" than in the "non-expert" (88% vs 79%; p=0.04) or in the "without ultrasound" groups (91% vs 78%; p=0.005). Incidence of complications was 11.7%, with no significant difference among "with ultrasound" (8.1%) and "without ultrasound" (14.9%) groups. However, the "non-expert" group had fewer complications with the use of ultrasound (7.8% vs 24%).

CONCLUSIONS

Ultrasound reduces the incidence of complications when placement is performed by inexperienced operators. Centers with residents should emphasize the necessity of ultrasound for central line catheterization. Training in ultrasound might be of paramount importance in the effectiveness of the technique.

Maternal mortality due to pandemic influenza A H1N1 2009 virus in Colombia

AIMS

The 2009 H1N1 pandemic illustrated the higher morbidity and mortality from viral infections in peripartum women. We describe clinical features of women who recently died of H1N1 in Colombia.

METHODS

This is a case series study that was gathered through a retrospective record review of all maternal H1N1 deaths in the country. The national mortality database of confirmed mortality from H1N1 in pregnancy and up to 42 days after delivery was reviewed during the H1N1 season in 2009. Women with H1N1 infections were confirmed by the laboratory of virology. Demographic, clinical, and laboratory data were reviewed. Statistical analyses were performed and median values of non-parametric data were reported with inter-quartile range (IQR).

RESULTS

A total of 23 H1N1 maternal deaths were identified. Eighty-three percent occurred in the third trimester. None of the mothers who died had received influenza vaccination. The median time from symptom onset to the initiation of antiviral treatment was 8.8 days (IQR 5.8-9.8). Five fatalities did not receive any anti-viral therapy. Median PaO2/FiO2 on day 1 was 80 (IQR, 60-98.5). All patients required inotropic support and mechanical ventilation with barotrauma-related complications of mechanical ventilation occurring in 35% of patients.

CONCLUSION

In Colombia, none of the women suffering H1N1-related maternal deaths had received vaccination against the disease and most had delayed or had no anti-viral therapy. Given the lack of evidence-based clinical predictors to identify women who are prone to die from H1N1 in pregnancy, following international guidelines for vaccination and initiation of antiviral therapy in suspected cases would likely improve outcomes in developing countries.

Seroprevalence of measles and rubella antibodies in pregnant women Haiti, 2012

BACKGROUND

Haiti had set a national goal to eliminate measles and rubella, as well as congenital rubella syndrome (CRS) by 2010. A 2007-2008 nationwide measles and rubella vaccination campaign targeting 1-19 years, however, reached only 79% of the target population. To assess whether population immunity was adequate to support elimination, we conducted a national serosurvey.

METHODS

We systematically selected 740 serum specimens collected from pregnant women in a 2012 national antenatal HIV sentinel serosurvey across four age strata: 15-19, 20-24, 25-29 and 30-39 years. Sera were tested for measles and rubella specific immunoglobulin G antibodies (IgG) using commercial immunoassays. We classified sera as seropositive, seronegative or indeterminate per manufacturer's instructions, and analyzed seroprevalence according to age strata, and rural or urban residence. We assessed immunity by estimating antibody concentrations in international units per milliliter (IU/mL) for seropositive and indeterminate sera. Measles IgG concentrations >0.12 IU/mL and rubella IgG concentrations >10 IU/mL were considered clinically protective.

RESULTS

Of 740 sera, 696 (94.1%) were seropositive and 20 (2.7%) were indeterminate for measles IgG; overall 716 (96.8%) sera had IgG concentrations >0.12 IU/mL. For rubella IgG, 691 (93.4%) sera were seropositive and 1 (0.1%) was indeterminate; a total of 687 (92.8%) had IgG concentrations >10 IU/mL. Measles seropositivity varied across age strata (p=0.003); seropositivity increased from 88.6% among 15-19 year olds to 98.4% among 30-39 year olds (Cochran-Armitage trend tes t ≤ 0.0001). Rubella seropositivity did not differ across age strata. There were no statistically significant differences in measles or rubella seropositivity by urban versus rural residence.

CONCLUSION

Despite previous low vaccination coverage for measles, results from this serosurvey indicate high levels of measles and rubella seropositivity in pregnant women, and contribute to the evidence for measles, rubella and CRS elimination from Haiti by the target date.