Successful long-term treatment of paediatric ulcerative colitis with vedolizumab: a case report

Biologics are recommended to treat paediatric ulcerative colitis (UC) that is chronically active or steroid-dependent despite aminosalicylic acids (5-ASA) and thiopurine treatments. Anti-tumour necrosis factor inhibitors (Anti-TNF inhibitors) are the agents of choice and vedolizumab could be considered as second-line biologic therapy.In the current case, we aim to describe a successful long-term treatment with vedolizumab in a 9-year-old boy with severe UC and primary non-response to infliximab. Concomitant azathioprine was used, and steroid refractoriness was also detected. Drug and anti-drug antibody levels were negative after infliximab induction so a switch to a 6-week-induction vedolizumab regimen followed by a maintenance regimen as a monotherapy was decided. The clinical response and tolerability to vedolizumab allowed long-term disease remission. Vedolizumab is currently non-authorised to treat paediatric patients and there is limited data on long-term treatments to date. This case contributes to the literature by adding evidence on the long-term efficacy and safety of vedolizumab in paediatric UC.

Economic Evaluation of Clinical, Nutritional and Rehabilitation Interventions on Oropharyngeal Dysphagia after Stroke: A Systematic Review

Background: Post-stroke oropharyngeal dysphagia (PS-OD) and its complications increase healthcare costs, suggesting that its appropriate management is cost-effective. We aimed to assess the efficiency of healthcare interventions in PS-OD management. Methods: A systematic review was conducted following PRISMA recommendations. Four databases were searched from inception through 30 June 2021. Outcome measures were cost-effectiveness and cost-savings of healthcare interventions. English and Spanish literature were included. Narrative and tables were used to present and synthesise evidence. Quality was evaluated using the CHEERS Statement. Results: A total of 244 studies were identified, and 10 were included. Screening and diagnosis of PS-OD studies found: (1) adjusted reduction in hospitalisation costs when assessed during the first admission day; (2) non-significant reduction in hospitalisation costs with OD management after thrombolysis; and (3) videofluoroscopy as the most cost-effective screening method (compared to bedside evaluation and a combination of both). Two studies showed cost-effective rehabilitation programmes, including OD management. Pelczarska et al. showed an incremental cost–utility ratio of texture-modified diets using a gum-based thickener of 20,977 PLN (4660€) following a dynamic model, and Kotecki et al. commercially prepared thickened fluids that were 44% to 59% less expensive than in situ prepared fluids. Elia et al. showed home enteral nutrition was cost-effective (£12,817/QALY), and Beavan et al. showed higher nutrient intake and low increase in hospitalisation costs using looped-nasogastric tubes (£5.20 for every 1% increase). Heterogeneity between studies precluded a quantitative synthesis. Conclusions: Included studies suggest that healthcare interventions aiming to prevent OD complications are cost-effective. However, studies assessing novel strategies are needed.

The management of polypharmacy in people living with HIV

Antiretroviral therapy (ART) has modified the prognosis of HIV which has evolved into a chronic condition. People living with HIV (PLWH) are living longer presenting an increased number of comorbidities leading to polypharmacy. Literature on the prevalence, associated factors, drug-drug interactions (DDIs), effects on ART-outcomes, geriatric conditions, and nutritional status together with health-interventions aimed to reduce it is presented in this review. A literature search was conducted on the MEDLINE database for all relevant English- and Spanish-language studies since 2006. Studies providing data of interest were identified and ordered in groups: (i) prevalence and associated factors (n = 37), (ii) DDIs (n = 19), (iii) Effects on ART-outcomes (n = 12), (iv) Effects on health conditions (n = 13), and (V) Health-interventions to assess and/or reduce it (n = 9). Polypharmacy occurs in 9-91% of PLWH (2.6-19.5% affected by severe polypharmacy). Main factors associated with polypharmacy are older age, a higher number of comorbidities, frailty, deteriorated renal function, and previous hospitalizations. DDIs were present in 19.15-84% of cases (1.3-12.2% for the most severe types). Mainly involved non-ART drugs were antihypertensives, statins, antithrombotic agents, corticosteroids, divalent cations, and antiacids. Polypharmacy can affect ART selection, adherence, and outcomes and has been related to some geriatric conditions such as falls, frailty, and poor nutritional status. Potentially prescribing issues are present in up to 87.9% of cases according to the STOPP-START and Beers criteria and some pharmacist-led interventions have been shown to reduce it. Considering these findings, polypharmacy should be considered a clinical concern in this population and treatment-optimization programs are needed to reduce its burden.

Health-related quality of life of X-linked hypophosphatemia in Spain

BACKGROUND

Health-related quality of life (HRQoL) of patients with X-linked hypophosphatemia (XLH) is lower than that of both the general population and the patients with other chronic diseases, mainly due to diagnostic delay, treatment difficulties, poor psychosocial support, and problems with social integration. Early diagnosis and optimal treatment are paramount to control the disease in patients with XLH, avoid complications, and maintain or improve their HRQoL. We, therefore, analyzed the HRQoL of pediatric and adult patients with XLH treated with conventional therapy in Spain.

RESULTS

We used several versions of the EuroQol-5 dimensions (EQ-5D) instrument according to the age of patients with XLH. Then we compared the HRQoL of patients to that of the general Spanish population. Children with XLH (n = 21) had moderate problems in walking about (61.9%), washing or dressing themselves (9.52%), and performing their usual activities (33.33%). They also felt moderate pain or discomfort (61.9%) and were moderately anxious or depressed (23.81%). Adults with XLH (n = 29) had lower HRQoL, with problems in walking (93%, with 3.45% unable to walk independently), some level of pain (86%, with 3.45% experiencing extreme pain), problems with their usual activities (80%) and self-care (> 50%), and reported symptoms of anxiety and/or depression (65%). There were important differences with the general Spanish population.

CONCLUSIONS

XLH impacts negatively on physical functioning and HRQoL of patients. In Spanish patients with XLH, the HRQoL was reduced despite conventional treatment, clearly indicating the need to improve the therapeutic approach to this disorder.

Real-world effectiveness and durability of dual antiretroviral therapy in HIV-infected patients

BACKGROUND AND OBJECTIVES

While randomised controlled trials in HIV-infected patients have shown that certain dual antiretroviral therapy (DAT) regimens are non-inferior in terms of efficacy compared with classical triple-drug regimens, few real clinical experiences have been described. The aim of the study was to investigate, in real clinical practice, DAT effectiveness, durability, and risk factors for treatment discontinuation.

METHODS

This was a prospective cohort study that included HIV-infected patients treated with DAT (2015-2020). DAT was considered effective when patients achieved or maintained virological suppression and was assessed at 24 and 48 weeks. DAT durability was evaluated using the Kaplan-Meier method. Adherence and treatment cost were compared with patients' previous antiretroviral regimens.

RESULTS

51 patients were included, 27.5% with HIV-1 RNA ≥50 copies/mL at baseline, treated with a wide range of dual combinations. At 48 weeks follow-up, 83.8% and 50.0% of patients who started DAT with HIV-1 RNA <50 copies/mL and ≥50 copies/mL, respectively, were suppressed. 39 out of 51 patients (76.5%) maintained DAT for a mean treatment duration of 40.5±14.8 weeks. Full adherence was observed in 78.4% of patients compared with 70.2% in the previous regimen. Mean daily cost was €18.6±4.3 compared with €16.1±7.9 in the previous regimen (p=0.008).

CONCLUSION

DAT effectiveness and durability were higher in patients who were virologically suppressed at baseline. DAT is a possible alternative for virologically non-suppressed patients who cannot be treated with a triple-drug regimen.

The Hydration Status of Adult Patients with Oropharyngeal Dysphagia and the Effect of Thickened Fluid Therapy on Fluid Intake and Hydration: Results of Two Parallel Systematic and Scoping Reviews

BACKGROUND

The effect of oropharyngeal dysphagia (OD) and thickened fluid (TF) therapy on hydration status has not been well defined in the literature. We aimed to assess the hydration status in patients with OD and the effect TF therapy has on it.

METHODS

Two literature reviews following PRISMA methodology (each one including a systematic and a scoping review) were performed: (R1) hydration status in adult patients with OD; (R2) effect of TF therapy on fluid intake and dehydration. Narrative and descriptive methods summarized both reviews. Quality assessment was assessed by Joanna Briggs Institute tools and GRADE.

RESULTS

(R1) Five out of twenty-two studies using analytical parameters or bioimpedance showed poorer hydration status among OD and 19-100% prevalence of dehydration; (R2) two high quality studies (total of 724 participants) showed positive effects of TF on hydration status. Among the articles included, nine out of ten studies that evaluated fluid intake reported a reduced TF intake below basal water requirements.

CONCLUSIONS

Dehydration is a highly prevalent complication in OD. There is scientific evidence on the positive effect of TF therapy on the hydration status of patients with OD. However, strict monitoring of fluid volume intake is essential due to the low consumption of TF in these patients.

Economic evaluations of health care interventions in oropharyngeal dysphagia after stroke: protocol for a systematic review

BACKGROUND AND PURPOSE

Oropharyngeal dysphagia (OD) affects 40-81% of patients after stroke. A recent systematic review on the costs of OD and its main complications showed higher acute and long-term costs for those patients who developed OD, malnutrition and pneumonia after stroke. These results suggest that appropriate management of post-stroke OD could reduce clinical complications and costs. The purpose of this systematic review is to assess the available literature for healthcare interventions that are efficient or cost-effective in the management of OD.

METHODS

A systematic review on economic evaluations of health care interventions will be performed on post-stroke patients with OD following PRISMA recommendations. Four bibliographic databases will be searched and a subsequent reference check will be done. English and Spanish literature will be included without date restrictions. Studies will be included if they refer to economic evaluations or in which cost savings were reported in post-stroke patients suffering OD. Studies will be excluded if they are partial economic evaluation studies, if they refer to esophageal dysphagia, or if OD is caused by causes different from stroke. Evidence will be presented and synthetised with a narrative method and using tables. Quality evaluation will be done using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

DISCUSSION

The protocol for this systematic review is the first step to assess the cost-effectiveness of the healthcare interventions that have been described as potential treatments for post-stroke OD. This systematic review will summarise the current evidence on the relation between cost and benefits associated with the appropriate management of OD in post-stroke patients.

TRIAL REGISTRATION

PROSPERO CRD42020136245.

Angular Momentum Removal by Neutron and γ-Ray Emissions during Fission Fragment Decays

We investigate the angular momentum removal from fission fragments (FFs) through neutron and γ-ray emission, finding that about half the neutrons are emitted with angular momenta ≥1.5ℏ and that the change in angular momentum after the emission of neutrons and statistical γ rays is significant, contradicting usual assumptions. Per fission event, in our simulations, the neutron and statistical γ-ray emissions change the spin of the fragment by 3.5-5ℏ, with a large standard deviation comparable to the average value. Such wide angular momentum removal distributions can hide any underlying correlations in the fission fragment initial spin values. Within our model, we reproduce data on spin measurements from discrete transitions after neutron emissions, especially in the case of light FFs. The agreement further improves for the heavy fragments if one removes from the analysis the events that would produce isomeric states. Finally, we show that while in our model the initial FF spins do not follow a sawtoothlike behavior observed in recent measurements, the average FF spin computed after neutron and statistical γ emissions exhibits a shape that resembles a sawtooth. This suggests that the average FF spin measured after statistical emissions is not necessarily connected with the scission mechanism as previously implied.

Cost-minimisation analysis of rectal cancer neoadjuvant chemoradiotherapy based on fluoropyrimidines (capecitabine versus 5-fluorouracil)

OBJECTIVES

The current standard treatment for patients with rectal cancer stage II-III is neoadjuvant chemoradiotherapy followed by surgery. Neoadjuvant chemoradiotherapy can be performed with 5-fluorouracil (5-FU) or capecitabine (CPC) considered to be equivalent therapies. Medication cost is higher for CPC than for 5-FU, however, the administration of continuous 5-FU intravenous infusion is related to other costs such as those associated with outpatient facilities or central venous catheter insertion.

METHODS

This retrospective study analysed the direct sanitary costs associated with the treatments and their complications from a hospital perspective. Costs in patients treated with 5-FU or CPC were measured between January 2010 and July 2018 at Mataró Hospital. The aim of this study was to perform a cost-minimisation analysis between the two treatments. We aimed to assess the cost associated with the complications related to each drug and the economic impact of applying the most efficient option.

RESULTS

Ninety-eight patients were analysed: 32 were treated with CPC and 66 with 5-FU. Treatment cost was significantly higher for 5-FU than for CPC (2560.86±99.17 and 563.10±9.52 respectively, P=0.0001). No significant differences were found in the costs associated with treatment complications between groups (148.21±934.91 and 41.41±102.50 euros respectively, P=0.322).

CONCLUSIONS

Considering the clinical equivalence shown in the available trials and previous reviews, the most efficient treatment is neoadjuvant chemoradiotherapy with CPC. Complications associated with the treatments did not significantly modify these results. Other studies gave similar results both in the neoadjuvant and adjuvant context, reaffirmed in this study.

Risk factors for nosocomial bloodstream infections in COVID-19 affected patients: protocol for a case-control study

BACKGROUND

Nosocomial bloodstream infection (nBSI) is an important clinical concern among COVID-19 hospitalised patients. It can cause sepsis and septic shock leading to high morbidity, mortality, and the emergence of antibiotic resistance. The aim of this case-control study is to identify the risk factors associated with the nBSI development in COVID-19 hospitalised patients and its incidence.

METHODS AND ANALYSIS

A retrospective case-control study will be performed. Cases will include nBSI episodes of adult patients (≥18 years) admitted to Hospital Universitari Germans Trias i Pujol, Barcelona, Spain, from April to December 2020 with a diagnosis of SARS-CoV-2 pneumonia. Patients transferred from other hospitals will be excluded. Controls will include hospitalisation episodes of COVID-19 patients without nBSI. We will recruit a minimum of 74 nBSI episodes (cases) and 74 controls (according to sample size calculation). We will collect data on sociodemographics, clinical status at admission, hospital admission, in-hospital mortality, and exposure data (use of antivirals, glucocorticoids or immunomodulatory agents, length of hospitalisation, and use of medical devices such as intravenous catheters). A bivariate and a subsequent multivariate regression analysis will be performed to assess the independent effect of the associated risk factors after adjusting for confounders. The nBSI incidence rate will be estimated according to the number of nBSI episodes in admitted COVID-19 patients among the total person-month of follow-up.

ETHICS AND DISSEMINATION

The protocol of this study was approved by the Ethical Committee for Drug Investigation of the Hospital Universitari Germans Trias i Pujol. The results of this case-control study will be published in a peer reviewed journal.

A Systematic and a Scoping Review on the Psychometrics and Clinical Utility of the Volume-Viscosity Swallow Test (V-VST) in the Clinical Screening and Assessment of Oropharyngeal Dysphagia

(1) Background: The volume-viscosity swallow test (V-VST) is a clinical tool for screening and diagnosis of oropharyngeal dysphagia (OD). Our aims were to examine the clinical utility of the V-VST against videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallow (FEES) and to map the V-VST usage with patients at risk of OD across the years since it was described for the first time, carrying a systematic and a scoping review. (2) Methods: We performed both a systematic review (SR) including studies that look at the diagnostic test accuracy, and a scoping review (ScR) with articles published from September 2008 to May 2020. Searches were done in different databases, including PubMed and EMBASE from September 2008 until May 2020, and no language restrictions were applied. A meta-analysis was done in the SR to assess the psychometric properties of the V-VST. Quality of studies was assessed by Dutch Cochrane, QUADAS, GRADE (SR), and STROBE (ScR) criteria. The SR protocol was registered on PROSPERO (registration: CRD42020136252). (3) Results: For the diagnostic accuracy SR: four studies were included. V-VST had a diagnostic sensitivity for OD of 93.17%, 81.39% specificity, and an inter-rater reliability Kappa = 0.77. Likelihood ratios (LHR) for OD were 0.08 (LHR-) and 5.01 (LHR+), and the diagnostic odds ratio for OD was 51.18. Quality of studies in SR was graded as high with low risk of bias. In the ScR: 34 studies were retrieved. They indicated that V-VST has been used internationally to assess OD's prevalence and complications. (4) Conclusions: The V-VST has strong psychometric properties and valid endpoints for OD in different phenotypes of patients. Our results support its utility in the screening and clinical diagnosis and management of OD.

[Metastatic Crohn's disease of the umbilicus: An exceptional location]

INTRODUCTION

Cutaneous manifestations of Crohn's disease are frequent and include metastatic lesions. These are separated from the digestive tract and affect particularly the limbs and major folds. Umbilical involvement is exceptional.

CASE REPORT

A 93-year-old woman followed for 6 years for Crohn's disease, in remission on infliximab, 5mg/kg every 8 weeks, consulted for a fissured and painful omphalitis. Histology revealed epithelioid granulomas without necrosis in the dermis, leading to the diagnosis of umbilical cutaneous metastasis of Crohn's disease. Infliximab intensification every 6 weeks led to a positive outcome.

CONCLUSION

We report a unique case of umbilical metastatic localization of Crohn's disease occurring during treatment with anti-TNF alpha. The diagnosis was based on skin biopsy and histology which found epithelioid granulomas without caseous necrosis.

Healthcare costs of post-stroke oropharyngeal dysphagia and its complications: malnutrition and respiratory infections

BACKGROUND AND PURPOSE

The healthcare economic costs of post-stroke oropharyngeal dysphagia (OD) are not fully understood. The purpose of this study was to assess the acute, subacute and long-term costs related to post-stroke OD and its main complications (malnutrition and respiratory infections).

METHODS

A cost of illness study of patients admitted to Mataró Hospital (Catalonia, Spain) from May 2010 to September 2014 with a stroke diagnosis was performed. OD, malnutrition and respiratory infections were assessed during hospitalization and follow-up (3 and 12 months). Hospitalization and long-term costs were measured from hospital and healthcare system perspectives. Multivariate linear regression analysis was performed to assess the independent effect of OD, malnutrition and respiratory infections on healthcare costs during hospitalization, and at 3 and 12 months' follow-up.

RESULTS

In all, 395 patients were included of whom 178 had OD at admission. Patients with OD incurred major total in-hospital costs (€5357.67 ± €3391.62 vs. €3976.30 ± €1992.58, p < 0.0001), 3-month costs (€8242.0 ± €5376.0 vs. €5320.0 ± €4053.0, p < 0.0001) and 12-month costs (€11,617.58 ± €12,033.58 vs. €7242.78 ± €7402.55, p < 0.0001). OD was independently associated with a cost increase of €789.68 (p = 0.011) during hospitalization and of €873.5 (p = 0.084) at 3 months but not at 12 months. However, patients with OD who were at risk of malnutrition or malnourished and suffered respiratory infections incurred major mean costs compared with those patients without OD (€19,817.58 ± €13,724.83 vs. €7242.8 ± €7402.6, p < 0.0004) at 12 months' follow-up.

CONCLUSION

Oropharyngeal dysphagia causes significant high economic costs during hospitalization that strongly and significantly increase with the development of malnutrition and respiratory infections at long-term follow-up.

Healthcare-related cost of oropharyngeal dysphagia and its complications pneumonia and malnutrition after stroke: a systematic review

OBJECTIVES

To assess the healthcare costs associated with poststroke oropharyngeal dysphagia (OD) and its complications (malnutrition, dehydration, pneumonia and death).

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

DATA SOURCES

MEDLINE, Embase and the National Health Service Economic Evaluation Database were searched up to 31 December 2019.

PARTICIPANTS

Patients with poststroke.

PRIMARY OUTCOME MEASURES

The costs associated to poststroke OD and its complications.

DATA ANALYSIS

Data were synthetised narratively, quality evaluation was done using an adaptation of Drummond's checklist and Grading of Recommendations Assessment, Development and Evaluation recommendations were used to assess strength of evidence.

RESULTS

A total of 166 articles were identified, of which 10 studies were included. The cost of OD during the hospitalisation was assessed in four studies. One prospective study showed an increase of US$6589 for patients requiring tube feeding. Two retrospective studies found higher costs for those patients who developed OD, (US$7329 vs US$5939) among patients with haemorrhagic stroke transferred to inpatient rehabilitation and an increase of €3000 (US$3950) and SFr14 000 (US$15 300) in hospitalisation costs. One study did not found OD as a predictor for total medical costs in the multivariate analysis. One retrospective study showed an increase of US$4510 during the first year after stroke for those patients with OD. For pneumonia, five retrospective studies showed an increase in hospitalisation costs after stroke of between US$1456 and US$27 633. One prospective study showed an increase in hospitalisation costs during 6 months after stroke in patients at high malnutrition risk. Strength of evidence was considered moderate for OD and pneumonia and low for malnutrition.

CONCLUSIONS

This systematic review shows moderate evidence towards higher costs for those patients who developed OD after stroke. The available literature is heterogeneous, and some important aspects have not been studied yet. Further studies are needed to define the specific cost of poststroke OD.

PROSPERO REGISTRATION NUMBER

CRD42018099977.

Hyaluronic acid treatment outcome on the post-extraction wound healing in patients with poorly controlled type 2 diabetes: A randomized controlled split-mouth study

Background

Hyaluronic acid is widely used in the medical field. However, there is a lack of research about its effect on patients with certain risks, such as compromised wound healing commonly found in patients with poorly controlled type 2 diabetes. The aim of this study is to investigate the efficacy of hyaluronic acid on the post-extraction wound healing and pain in patients with poorly controlled type 2 diabetes.

Material and Methods

The randomized controlled split-mouth study was designed, which included 30 patients with poorly controlled type 2 diabetes with a bilaterally same teeth in the lower jaw for extraction. The sockets treated with 0.8% hyaluronic acid represented the study group, while the sockets where hyaluronic acid was not applied represented the control group. Wound closure rate (WCR), clinical scores in wound healing scale (WHS) and pain intensity in Visual analogue scale (VAS) were recorded. Patients were followed up on 5th, 10th, 15th, 20th, 25th day after tooth extraction.

Results

The results showed a higher WCR at the extraction site where hyaluronic acid was applied. Also, statistically significant difference was found (p< 0.001). In regards to WHS, the sockets treated with hyaluronic acid showed better healing, especially on day 10 (p=0.006) and day 15 (p=0.021). However, there were no statistically significant differences in VAS scores between groups.

Conclusions

Hyaluronic acid placed in post-extraction socket in patients with poorly controlled diabetes may improve wound healing, especially in the first days after application.

Key words:Hyaluronic acid, type 2 diabetes mellitus, post-extraction wound healing, wound closure measurement.

Defective Conduction of Anorectal Afferents Is a Very Prevalent Pathophysiological Factor Associated to Fecal Incontinence in Women

Background/Aims

Fecal incontinence (FI) is a prevalent condition among women. While biomechanical motor components have been thoroughly researched, anorectal sensory aspects are less known. We studied the pathophysiology of FI in community-dwelling women, specifically, the conduction through efferent/afferent neural pathways.

Methods

A cross-sectional study was conducted on 175 women with FI and 19 healthy volunteers. The functional/structural study included anorectal manometry/endoanal ultrasound. Neurophysiological studies including pudendal nerve terminal motor latency (PNTML) and sensory-evoked-potentials to anal/rectal stimulation (ASEP/RSEP) were conducted on all healthy volunteers and on 2 subgroups of 42 and 38 patients, respectively.

Results

The main conditions associated with FI were childbirth (79.00%) and coloproctological surgery (37.10%). Cleveland score was 11.39 ± 4.09. Anorectal manometry showed external anal sphincter and internal anal sphincter insufficiency in 82.85% and 44.00%, respectively. Sensitivity to rectal distension was impaired in 27.42%. Endoanal ultrasound showed tears in external anal sphincter (60.57%) and internal anal sphincter disruptions (34.80%). Abnormal anorectal sensory conduction was evidenced through ASEP and RSEP in 63.16% and 50.00% of patients, respectively, alongside reduced activation of brain cortex to anorectal stimulation. In contrast, PNTML was delayed in only 33.30%. Stools were loose/very loose in 56.70% of patients.

Conclusions

Pathophysiology of FI in women is mainly associated with mechanical sphincter dysfunctions related to either muscle damage or, to a lesser extent, impaired efferent conduction at pudendal nerves. Impaired conduction through afferent anorectal pathways is also very prevalent in women with FI and may play an important role as a pathophysiological factor and as a potential therapeutic target.

The effectiveness of decompression as initial treatment for jaw cysts: A 10-year retrospective study

Background

Decompression is an approved alternative to cystectomy in the treatment of jaw cysts. This study aimed to evaluate its effectiveness as an initial procedure, as well as factors with potential to influence outcome.

Material and Methods

The frequency of decompression was analysed, whether completed in one session or followed by enucleation at the Division of Oral Surgery and Orthodontics, Department of Dental Medicine and Oral Health, Medical University of Graz, from 2005 to 2015. Further analysis focussed on factors potentially influencing outcome: cyst location, histopathology, means of preserving the cyst opening, cyst size, patient age.

Results

In all, 53 patients with 55 jaw cysts (mean age of 35.1) were treated by initial decompression in the ten-year period. In the majority of cases, histopathological analysis revealed a follicular cyst (43.6%), followed by odontogenic keratocysts (23.7%), radicular cysts (21.8%), residual cysts (7.3%) and nasopalatine cysts (3.6%) Treatment was completed with a single decompression in 45.5% of the cases. Among those, 72.0% were follicular cysts and 8.0% odontogenic keratocysts. Subsequent enucleation was needed in 54.5% of all cases, with a majority in the keratocystic group (36.7%). Histological findings, means of keeping the cyst open, and patient age were found to influence the effectiveness of decompression.

Conclusions

Decompression could be performed as a procedure completed in one session or combined with subsequent enucleation, mainly dependent on histopathological findings. Subsequent enucleation of odontogenic keratocysts is highly recommended.

Key words:Jaw cysts, decompression, enucleation, histopathology, obturator.

Cost of oropharyngeal dysphagia after stroke: protocol for a systematic review

INTRODUCTION

Oropharyngeal dysphagia (OD) is a major disorder following stroke. OD can produce alterations in both the efficacy and safety of deglutition and may result in malnutrition, dehydration, frailty, respiratory infections and pneumonia. These complications can be avoided by early detection and treatment of OD in poststroke patients, and hospital stays, medication and mortality rates can be reduced. In addition to acute in-hospital costs from OD complications, there are other costs related to poststroke OD such as direct non-healthcare costs or indirect costs. The objective of this systematic review is to assess and summarise literature on the costs related to OD in poststroke patients.

METHODS AND ANALYSIS

A systematic review of studies on the cost of OD and its complications (aspiration, malnutrition, dehydration, aspiration pneumonia and death) in patients who had a stroke will be performed from the perspectives of the hospital, the healthcare system and/or the society. The main outcomes of interest are the costs related to poststroke OD. We will search MEDLINE, Embase and the National Health Service Economic Evaluation Database. Studies will be included if they are partial economic evaluation studies, studies that provide information on costs in adult (>17 years) poststroke patients with OD and/or its complications (malnutrition, dehydration, frailty, respiratory infections and pneumonia) or economic evaluation studies in which the cost of this condition has been estimated. Studies will be excluded if they refer to oesophageal dysphagia or OD caused by causes other than stroke. Main study information will be presented and summarised in tables, separately for studies that provide incremental costs attributable to OD or its complications and studies that report the effect of OD or its complications on total costs of stroke, and according to the perspective from which costs were measured.

ETHICS AND DISSEMINATION

The results of this systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018099977.

Successful desensitization to cloxacillin in a patient with sepsis, with infective endocarditis and clinical suspicion of hypersensitivity to penicillins, a case report

WHAT IS KNOWN AND OBJECTIVE

Beta-lactam antibiotic (BLA) therapy is frequently needed to treat infective endocarditis (IE). Hypersensitive reactions to BLA restrict BLA therapy in allergic patients. In the current case, we aim to describe the utility of desensitization (DS) in this context. Although the evidence is limited, DS is recommended.

CASE DESCRIPTION

This case report deals with a 79-year-old woman with a clinical suspicion of allergy to BLA and a methicillin-sensitive Staphylococcus aureus (MSSA) IE. A cloxacillin DS protocol was developed to enable treatment with cloxacillin.

WHAT IS NEW AND CONCLUSION

Alternative antibiotic treatments may be less effective or not available in MSSA IE. In this case report, DS allowed optimal cloxacillin treatment.

Modelling the effect of pH and water activity in the growth of Aspergillus fumigatus isolated from corn silage

AIMS

The aim of this work was to use mathematical kinetic modelling to assess the combined effects of a_W, pH, O₂ availability and temperature on the growth rate and time to growth of Aspergillus fumigatus strains isolated from corn silage.

METHODS AND RESULTS

A full factorial design was used in which two factors were assayed: pH and a_W . The a_W levels assayed were 0·80, 0·85, 0·90, 0·92, 0·94, 0·96, 0·98 and 0·99. The levels of pH assayed were 3·5, 4, 4·5, 5, 6, 7, 7·5 and 8. The assay was performed at normal oxygen tension at 25 and 37°C, and at reduced oxygen tension at 25°C. Two strains of A. fumigatus isolated from corn silage were used. Kinetic models were built to predict growth of the strain under the assayed conditions. The cardinal models gave a good quality fit for radial growth rate data. The results indicate that the environmental conditions which take place during silage production, while limiting the growth of most micro-organisms, would not be able to control A. fumigatus. Moreover, pH levels in silage, far from limiting its growth, are also close to its optimum. Carbon dioxide at 5% in the environment did not significantly affect its growth.

CONCLUSIONS

A need for a further and controlled acidification of the silage exists, as no growth of A. fumigatus was observed at pH 3·5, as long as the organoleptic characteristics of the silage are not much compromised.

SIGNIFICANCE AND IMPACT OF THE STUDY

Aspergillus fumigatus is one of the major opportunistic pathogens able to cause illness such as allergic bronchopulmonary aspergillosis, aspergilloma and invasive aspergillosis to rural workers. Exposure of animals to A. fumigatus spores can result in infections, particularly in those organs exposed to external invasion, such as the airways, mammary gland and uterus at birth.

Occurrence of Ochratoxigenic Fungi and Ochratoxin A in Green Coffee from Different Origins

Fungal infection and ochratoxin A (OTA) contamination were determined in green coffee samples from different origins, in which OTA-producing fungi were also identified. About 72% of the beans analysed by direct plating presented fungal infection, including species of Aspergillus, Penicillium and Rhizopus. The genus Aspergillus was presented in more than 90% of infected coffee beans. Aspergillus ochraceus and Aspergillus section Nigri isolates represented 2.8 and 65.4%, respectively from the total number of isolates from the coffee beans. The capacity to produce OTA was determined in 260 isolates of A. section Nigri and 19 of A. ochraceus by the agar plug method, giving positive results for 6% of the A. section Nigri isolates and 16% of the A. ochraceus. OTA production was analysed by high performance liquid chromatography. OTA contamination of green coffee beans was analysed by enzyme immunoassay. OTA levels in all samples analysed were above the limit of detection (0.6 mg/kg), with a mean OTA concentration of 6.7 mg/kg.

Bioaccessibility of ochratoxin A from red wine in an in vitro dynamic gastrointestinal model

Ochratoxin A (OTA) is a mycotoxin produced by Aspergillus and Penicillium species with immunosuppressive, teratogenic, and carcinogenic properties. It has been determined that wine is the second largest source of OTA (10% of total OTA intake) in the European diet and that its presence, even in small doses, can be a problem in terms of long-term toxicity. In this paper, we evaluated the bioaccessibility of OTA in a spiked red wine sample under human fasting conditions using an in vitro dynamic digestion model that includes a continuous-flow dialysis system to simulate intestinal passage. To the best of our knowledge, this report is the first examining the bioaccessibility of OTA in wine. A liquid-liquid method was used to extract the OTA and ochratoxin alpha (OTα) from gastrointestinal juices, and the extracts were analysed by HPLC with a fluorescence detector. The bioaccessibility of OTA from the spiked red wine (1.0, 2.0 and 4 μg/l) was high in the gastric compartment (102.8, 128.3 and 122.3%, respectively), whereas in the simulated intestine, it did not exceed 26%, and the amount of OTA that crossed the dialysis membrane was very low (<3.3%). The amount of OTα in gastric chyme ranged from 5.1 to 19.1% of the spiked OTA, whereas in the intestinal compartment it did not exceed 5%. In conclusion, in the in vitro system assayed, OTA exhibited a high bioaccessibility in the simulated stomach, but it decreased after the intestinal digestion and passage through the dialysis membrane.

A Bayesian methodology to improve prediction of early graft loss after liver transplantation derived from the liver match study

BACKGROUND

To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry.

METHODS

Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis.

RESULTS

A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76).

CONCLUSION

Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.

Mycotoxins: occurrence, toxicology, and exposure assessment

Mycotoxins are abiotic hazards produced by certain fungi that can grow on a variety of crops. Consequently, their prevalence in plant raw materials may be relatively high. The concentration of mycotoxins in finished products is usually lower than in raw materials. In this review, occurrence and toxicology of the main mycotoxins are summarised. Furthermore, methodological approaches for exposure assessment are described. Existing exposure assessments, both through contamination and consumption data and biomarkers of exposure, for the main mycotoxins are also discussed.

Bleeding risk in warfarinized patients with a therapeutic international normalized ratio: the effect of low factor IX levels

OBJECTIVE

Bleeding is the main complication of warfarin therapy, even patients with an international normalized ratio (INR) in the target range can suffer bleeding, suggesting that INR does not perfectly reflect the therapeutic effect of warfarin. We hypothesized the INR might underestimate the level of anticoagulation in a subject with a lower factor (F) IX level than average.

METHODS AND RESULTS

We modeled warfarin anticoagulation in our in vitro thrombin generation (TG) model by adjusting the levels of vitamin K-dependent factors to those of patients with an INR of 2-3. Variation in FIX had a marked effect on TG but had no effect on the prothrombin time (PT)-INR. A prospective observational, cross-sectional clinical study including 341 consecutive patients admitted to the emergency department with an INR between 2 and 3, showed a statistically lower FIX activity in bleeders (P = 0.004) compared with others. No correlation was found between TG capacity and PT-INR results (P = 0.36). However, in patients, presenting with a warfarin-related hemorrhage, TG was significantly lower (P < 0.001) than others. A correlation on the boundary of significance was observed between TG capacity and FIX levels (P = 0.09).

CONCLUSION

These data demonstrates that patients who bleed when their PT-INR is in the target range 2-3 might have defective TG related to a lower level of FIX than expected.

[The use of allografts in the surgical treatment of enlarged hiatal hernias]

The use of allografts in the surgical treatment of enenlarged hiatal hernias is a current hot topic of discussion. Using meshes in order to strengthen the hiatus of the esophagus is an efficient procedure which reduces the risk of reoccurences. In order to consolidate the initial surgical treatment of the enlarged hiatal hernias, polypropylene, polytetrafluoroethylene and biomaterial meshes are mainly used. There are ongoing discussions with regards to the use of meshes, their type and positioning. Although mesh usage is associated with a low recurrence rate, numerous authors have described complications such as: meshes migrating into the esophagus (caused by the alloplastic material used in the hiatoplasty), strictures, dysphagia, ulcers or perforations. From experience, the mesh used in the surgical treatment of hiatal hernia should preferably be non-biological and must be placed circumferentially, while fermly grounded at the pillar of the diaphragm. The correct placing of the mesh lowers the risk of strictures and degradation. Further prospective studies are needed in order to clarify the best method of surgically treating enlarged hiatal hernias.

In vitro effect of some fungicides on growth and aflatoxins production by Aspergillus flavus isolated from Capsicum powder

The aim of this study was to determine the effect of some pre-harvest fungicides on growth and aflatoxin (AF) production of three Aspergillus flavus strains found in Capsicum powder. Each isolate, previously isolated from paprika, chilli and smoked paprika, was inoculated on yeast extract sucrose agar and on a 3% paprika extract agar medium supplemented with different fungicides and incubated at 20 and 30°C during 7 days. Growth measurements were obtained on days 3, 5 and 7, and the AF production was determined on day 7. The significance of the effects of the factors (strain, medium, temperature, time and fungicides) and their interaction over colony diameter and AF production was determined. Temperature constrained the effectiveness of fungicides in reducing growth, the fungicides being most effective at 20°C. The efficacy of the fungicides over AF production depended on the medium used and temperature. The most effective fungicides in inhibiting growth and AF production, regardless of the strain tested or applied conditions, were tebuconazole 25% and mancozeb 80% applied at a concentration of 0.75 and 3.5 g l(-1), respectively. Care should thus be taken in the choice of a suitable fungicide because their effectiveness may depend on intra-specific variation and temperature. Moreover, it is necessary to take into account that the most efficient fungicide in reducing growth is not always the best choice for pre-harvest treatments because it may promote AF production. Thus, the best fungicide is the one that can simultaneous prevent growth and AF production.

Congener profile, occurrence and estimated dietary intake of dioxins and dioxin-like PCBs in foods marketed in the Region of Valencia (Spain)

During 2006-2008, a monitoring program was conducted on 29 target compounds, including PCDD/Fs and dl-PCBs, comprising 150 randomly collected individual food samples marketed in the Region of Valencia, Spain, grouped into 8 categories (vegetables, cereals, fats and oils, eggs, milk and dairy products, fish products, meat and meat products and fish oil). For PCDD/Fs, the highest frequency of detection corresponds to 1,2,3,4,6,7,8-HpCDD, OCDD, 2,3,4,7,8-PeCDF; and PCBs 118, 105 and 156 were the more frequent dl-PCBs. The food groups presenting higher contamination, expressed as toxic equivalents (WHO-TEQs), were fish oil (6.38 pg WHO-TEQ g(-1)fat), fish (1.21 pg WHO-TEQ g(-1)w.w.) and milk and dairy products (0.90 pg WHO-TEQ g(-1)fat). Of all analysed samples, only two fish oils presented levels higher than the EU limits for total WHO-TEQ. The average PCDD/Fs and dl-PCBs intakes were estimated as 2.86 pg WHO-TEQ kg(-1)b.w.d(-1) and 4.58 pg WHO-TEQ kg(-1)b.w.d(-1), for adults and children, respectively, using the deterministic method for chronic exposure. The main contributors to total intake for adults were fish (59%), milk and dairy products (19%), and fat and oils (9%). The average daily intake for adults (2.86 pg WHO-TEQ kg(-1)b.w.d(-1)) is within range of TDI recommended by the WHO (1-4 pg WHO-TEQ kg(-1)b.w.d(-1)), and slightly above the TWI and PTMI adopted by SCF and JECFA respectively.

Biomonitoring of Fusarium spp. Mycotoxins: Perspectives for an Individual Exposure Assessment Tool

Fusarium species are probably the most prevalent toxin-producing fungi of the northern temperate regions and are commonly found on cereals grown in the temperate regions of America, Europe and Asia. Among the toxins formed by Fusarium we find trichothecenes of the A-type or B-type, zearalenone, fumonisins or nivalenol. The current exposure assessment consists of the qualitative and/or quantitative evaluation based on the knowledge of the mycotoxin occurrence in the food and the dietary habits of the population. This process permits quantifying the mycotoxin dietary intake through deterministic or probabilistic methods. Although these methods are suitable to assess the exposure of populations to contaminants and to identify risk groups, they are not recommended to evaluate the individual exposition, due to a low accuracy and sensitivity. On the contrary, the use of biochemical indicators has been proposed as a suitable method to assess individual exposure to contaminants. In this work, several techniques to biomonitor the exposure to fumonisins, deoxynivalenol, zearalenone or T-2 toxin have been reviewed.

Review. Ochratoxin A: Presence in Human Plasma and Intake Estimation

Ochratoxin A (OTA) is a fungal toxic secondary metabolite that can be found in several foodstuffs and thereby ingested by humans. One way to assess exposure of humans to OTA is the determination of the levels of this mycotoxin in blood plasma from a certain population. Such studies have been done in many countries, both in healthy people and nephropathy patients. Relationships with individual characteristics were investigated in several cases. Thus, most studies found no correlation with age, either with gender. However, the few studies that found correlation between OTA plasma levels and gender showed that men presented the highest values. When sampling was done over more than one season, the highest OTA plasma levels were found mostly in summer. Differences within regions of a country were related to dietary habits of each area. OTA levels of group populations showed variations from year to year, whereas intraindividual repetitions showed no specific trend. Daily intake of the toxin can be estimated from OTA plasma concentrations by the Klaassen equation. OTA toxicokinetics are considered in this review. Calculated daily intake of OTA by different studies did not overpass the proposed tolerable daily intakes of OTA.