Multidrug resistance in Salmonella isolates of swine origin: mobile genetic elements and plasmids associated with cephalosporin resistance with potential transmission to humans

The emergence of foodborne Salmonella strains carrying antimicrobial resistance (AMR) in mobile genetic elements (MGE) is a significant public health threat in a One Health context requiring continuous surveillance. Resistance to ciprofloxacin and cephalosporins is of particular concern. Since pigs are a relevant source of foodborne Salmonella for human beings, we studied transmissible AMR genes and MGE in a collection of 83 strains showing 9 different serovars and 15 patterns of multidrug resistant (MDR) previously isolated from pigs raised in the conventional breeding system of Northern Spain. All isolates were susceptible to ciprofloxacin and three isolates carried blaCMY-2 or blaCTX-M-9 genes responsible for cefotaxime resistance. Filter mating experiments showed that the two plasmids carrying blaCTX-M-9 were conjugative while that carrying blaCMY-2 was self-transmissible by transformation. Whole-genome sequencing and comparative analyses were performed on the isolates and plasmids. The IncC plasmid pSB109, carrying blaCMY-2, was similar to one found in S. Reading from cattle, indicating potential horizontal transfer between serovars and animal sources. The IncHI2 plasmids pSH102 in S. Heidelberg and pSTM45 in S. Typhimurium ST34, carrying blaCTX-M-9, shared similar backbones and two novel "complex class 1 integrons" containing different AMR and heavy metal genes. Our findings emphasize the importance of sequencing techniques to identify emerging AMR regions in conjugative and stable plasmids from livestock production. The presence of MGE carrying clinically relevant AMR genes raises public health concerns, requiring monitoring to mitigate the emergence of bacteria carrying AMR genes and subsequent spread through animals and food.IMPORTANCEThe emergence of foodborne Salmonella strains carrying antimicrobial resistance (AMR) in mobile genetic elements (MGE) is a significant public health threat in a One Health context. Since pigs are a relevant source of foodborne Salmonella for humans, in this study, we investigate different aspects of AMR in a collection of 83 Salmonella showing nine different serovars and 15 patterns of multidrug resistant (MDR) isolated from pigs raised in the conventional breeding system. Our findings emphasize the importance of sequencing techniques to identify emerging AMR regions in conjugative and stable plasmids from livestock production. The presence of MGE carrying clinically relevant AMR genes raises public health concerns, requiring monitoring to mitigate the emergence of bacteria carrying AMR genes and subsequent spread through animals and food.

Persistent COVID-19: a case report of an immunocompromised patient and a literature review

Introduction Immunocompromised patients can show prolonged shedding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and persistent symptoms, which is called persistent COVID-19. Case presentation We report a case of an immunocompromised patient who was treated for mantle cell lymphoma and was suffering from B-cell depletion. The patient developed persistent COVID-19, which was confirmed by real-time polymerase chain reaction (RT-PCR) tests in only sputum and bronchoalveolar fluid which remained positive for at least 112 days. The patient was successfully treated with SARS-CoV-2 convalescent plasma. Conclusion It could be of interest to investigate the RT-PCR results of SARS-CoV-2 in sputum/bronchoalveolar lavage samples from immunocompromised patients with unexplained pneumonia.

Engineered live bacteria suppress Pseudomonas aeruginosa infection in mouse lung and dissolve endotracheal-tube biofilms

Engineered live bacteria could provide a new modality for treating lung infections, a major cause of mortality worldwide. In the present study, we engineered a genome-reduced human lung bacterium, Mycoplasma pneumoniae, to treat ventilator-associated pneumonia, a disease with high hospital mortality when associated with Pseudomonas aeruginosa biofilms. After validating the biosafety of an attenuated M. pneumoniae chassis in mice, we introduced four transgenes into the chromosome by transposition to implement bactericidal and biofilm degradation activities. We show that this engineered strain has high efficacy against an acute P. aeruginosa lung infection in a mouse model. In addition, we demonstrated that the engineered strain could dissolve biofilms formed in endotracheal tubes of patients with ventilator-associated pneumonia and be combined with antibiotics targeting the peptidoglycan layer to increase efficacy against Gram-positive and Gram-negative bacteria. We expect our M. pneumoniae-engineered strain to be able to treat biofilm-associated infections in the respiratory tract.

Tocilizumab versus anakinra in COVID-19: results from propensity score matching

Background

Tocilizumab and anakinra are anti-interleukin drugs to treat severe coronavirus disease 2019 (COVID-19) refractory to corticosteroids. However, no studies compared the efficacy of tocilizumab versus anakinra to guide the choice of the therapy in clinical practice. We aimed to compare the outcomes of COVID-19 patients treated with tocilizumab or anakinra.

Methods

Our retrospective study was conducted in three French university hospitals between February 2021 and February 2022 and included all the consecutive hospitalized patients with a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection assessed by RT-PCR who were treated with tocilizumab or anakinra. A propensity score matching was performed to minimize confounding effects due to the non-random allocation.

Results

Among 235 patients (mean age, 72 years; 60.9% of male patients), the 28-day mortality (29.4% vs. 31.2%, p = 0.76), the in-hospital mortality (31.7% vs. 33.0%, p = 0.83), the high-flow oxygen requirement (17.5% vs. 18.3%, p = 0.86), the intensive care unit admission rate (30.8% vs. 22.2%, p = 0.30), and the mechanical ventilation rate (15.4% vs. 11.1%, p = 0.50) were similar in patients receiving tocilizumab and those receiving anakinra. After propensity score matching, the 28-day mortality (29.1% vs. 30.4%, p = 1) and the rate of high-flow oxygen requirement (10.1% vs. 21.5%, p = 0.081) did not differ between patients receiving tocilizumab or anakinra. Secondary infection rates were similar between the tocilizumab and anakinra groups (6.3% vs. 9.2%, p = 0.44).

Conclusion

Our study showed comparable efficacy and safety profiles of tocilizumab and anakinra to treat severe COVID-19.

Engineering a genome-reduced bacterium to eliminate Staphylococcus aureus biofilms in vivo

Bacteria present a promising delivery system for treating human diseases. Here, we engineered the genome‐reduced human lung pathogen Mycoplasma pneumoniae as a live biotherapeutic to treat biofilm‐associated bacterial infections. This strain has a unique genetic code, which hinders gene transfer to most other bacterial genera, and it lacks a cell wall, which allows it to express proteins that target peptidoglycans of pathogenic bacteria. We first determined that removal of the pathogenic factors fully attenuated the chassis strain in vivo. We then designed synthetic promoters and identified an endogenous peptide signal sequence that, when fused to heterologous proteins, promotes efficient secretion. Based on this, we equipped the chassis strain with a genetic platform designed to secrete antibiofilm and bactericidal enzymes, resulting in a strain capable of dissolving Staphylococcus aureus biofilms preformed on catheters in vitro, ex vivo, and in vivo. To our knowledge, this is the first engineered genome‐reduced bacterium that can fight against clinically relevant biofilm‐associated bacterial infections.

Phage Lytic Protein LysRODI Prevents Staphylococcal Mastitis in Mice

Phage lytic proteins are promising antimicrobials that could complement conventional antibiotics and help to combat multi-drug resistant bacteria that cause important human and animal infections. Here, we report the characterization of endolysin LysRODI (encoded by staphylophage phiIPLA-RODI) and its application as a prophylactic mastitis treatment. The main properties of LysRODI were compared with those of endolysin LysA72 (encoded by staphylophage phiIPLA35) and the chimeric protein CHAPSH3b (derived from the virion-associated peptidoglycan hydrolase HydH5 and lysostaphin). Time-kill experiments performed with Staphylococcus aureus and Staphylococcus epidermidis demonstrated that the killing rate of LysRODI and CHAPSH3b is higher than that of LysA72 (0.1 μM protein removed 10⁷ CFU/ml of S. aureus in 30 min). Of note, all proteins failed to select resistant mutants as bacterial exposure to sub-lethal concentrations of the proteins did not alter the MIC values. Additionally, LysRODI and CHAPSH3b were non-toxic in a zebrafish embryo model at concentrations near the MIC (0.5 and 0.7 μM, respectively). Moreover, these two proteins significantly reduced mortality in a zebrafish model of systemic infection. In contrast to LysRODI, the efficacy of CHAPSH3b was dose-dependent in zebrafish, requiring higher-dose treatments to achieve the maximum survival rate. For this reason, LysRODI was selected for further analysis in mice, demonstrating great efficacy to prevent mammary infections by S. aureus and S. epidermidis. Our findings strongly support the use of phage lytic proteins as a new strategy to prevent staphylococcal mastitis.

Salmonella Infection in Mesenteric Lymph Nodes of Breeding Sows

Salmonellosis is one of the main foodborne diseases worldwide. Breeding sows asymptomatically infected with Salmonella can transmit the pathogen to piglets and humans. The isolation of Salmonella from mesenteric lymph nodes (MLNs) is considered a demonstration of asymptomatic infection in swine. As previous breeding sow studies have been performed using feces, the aim of this work was to study the occurrence of Salmonella infections by sampling MLNs, in comparison to their serological status. First, Salmonella fecal shedding was studied in 12/16 large breeding farms to establish the framework of study. Then, MLN (n = 264) and blood (n = 237) samples were obtained at an abattoir from sows of 15 of these 16 breeding farms. Additionally, risk factors associated with Salmonella MLN infection were analyzed. A total of 6.1% (16/264) sows, distributed in 40% (6/15) of the farms, had the pathogen in MLN. Salmonella Typhimurium was the most frequent serovar isolated. Interestingly, 43.8% (7/16) of MLN isolates were susceptible to all the antimicrobials tested and were found distributed throughout all farms with at least one sow positive. As well, one isolate of the emerging DT195 clone was detected and found to be resistant to six antibiotic families (ASSuTNx-Cfx). The serovars and the resistance profiles of the Salmonella isolates from feces were completely different to those obtained from MLNs. The seroprevalence (41.8% of sows and 100% of farms) was higher than that of MLN infections, showing no concordance (k = 0.15) between these two diagnostic tests in sows. Strategies directed to correct two risk factors (i.e., administration of dry food and old premises) would most likely help to reduce Salmonella infections in breeding sows.

Examining relationships between psychotic experiences and suicidal ideation in adolescents using a network approach

BACKGROUND

Suicide is one of the leading causes of death in young individuals. Timely and adequate identification of individuals with suicidal ideation could prevent from suicidal behavior. Psychotic experiences (PE) have been shown to increase levels of suicidal ideation (SI) in the general population. Therefore, detailed investigation of the relationship of PE and SI is relevant. However, the exact nature of the relationship between these two phenomena remains unclear. Understanding psychopathology as a complex network of interacting symptoms could be helpful to elucidate specific associations existing between PE and SI.

METHOD

A specific type of network analysis, the Ising model, was used to examine connections between dichotomized questions on psychotic experiences and suicidal ideation in a cross-sectional study with 1685 adolescents from the general population aged 13-18 years.

RESULTS

SI was mostly connected to the PE domains perceptual anomalies (PA) and bizarre experiences (BE), which have higher strength values in the network. Central nodes within these domains, as indexed by higher centrality measures (strength and betweenness) were: auditory experiences (PA1: hearing voices when you are alone), persecutory ideation (BE1: feelings of being persecuted; BE2: conspiracy against you), and social anxiety (SANX) (SANX1: I cannot get close to people).

CONCLUSIONS

Suicidal ideation is differentially connected to specific psychotic experiences. Auditory PE, persecutory ideation, and social anxiety symptoms could play a central role in the interconnectedness of the two constructs.

Relationship between Salmonella infection, shedding and serology in fattening pigs in low-moderate prevalence areas

Salmonella is a major foodborne pathogen causing important zoonosis worldwide. Pigs asymptomatically infected in mesenteric lymph nodes (MLN) can be intermittent shedders of the pathogen through faeces, being considered a major source of human infections. European baseline studies of fattening pig salmonellosis are based on Salmonella detection in MLN. This work studies the relationship between Salmonella infection in MLN and intestinal content (IC) shedding at slaughter and the relationship between the presence of the pathogen and the serologic status at farm level. Mean Salmonella prevalence in the selected pigs (vertically integrated production system of Navarra, Spain) was 7.2% in MLN, 8.4% in IC and 9.6% in serum samples. In this low-moderate prevalence context, poor concordance was found between MLN infection and shedding at slaughter and between bacteriology and serology. In fact, most of shedders were found uninfected in MLN (83%) or carrying different Salmonella strains in MLN and in IC (90%). The most prevalent Salmonellae were Typhimurium resistant to ACSSuT ± Nx or ASSuT antibiotic families, more frequently found invading the MLN (70%) than in IC (33.9%). Multivariable analysis revealed that risk factors associated with the presence of Salmonella in MLN or in IC were different, mainly related either to good hygiene practices or to water and feed control, respectively. Overall, in this prevalence context, detection of Salmonella in MLN is an unreliable predictor of faecal shedding at abattoir, indicating that subclinical infections in fattening pigs MLN could have limited relevance in the IC shedding.

Neuropsychiatric Symptoms in Patients With Alzheimer's Disease: The Role of Caregiver Burden and Coping Strategies

This study was conducted to obtain data regarding the association of caregiver burden (CB) and neuropsychiatric symptoms (NPSs) in patients with Alzheimer's disease. We conducted a series of multiple linear regressions to determine the relationship between CB and NPSs and whether the caregiver coping strategies mediated this relationship. The NPSs were assessed using the Neuropsychiatric Inventory, and caregivers were evaluated with the Caregiver Burden Interview and the Inventory and the Coping Strategies Inventory. Results show that patients with more frequent and severe NPS were more likely to be cared for by more burdened caregivers, and this was partially mediated by caregiver coping strategies. More disengagement (β = .330,P< .001) and less engagement coping (β = -.347,P< .001) were predictors for NPS after adjusting for patient and caregiver characteristics. These results may be useful with a view to designing treatment interventions that aim to modify the use of caregiver coping strategies and to reduce NPSs.

Simultaneous infections by different Salmonella strains in mesenteric lymph nodes of finishing pigs

BACKGROUND

Salmonellosis is a major worldwide zoonosis, and Salmonella-infected finishing pigs are considered one of the major sources of human infections in developed countries. Baseline studies on salmonellosis prevalence in fattening pigs in Europe are based on direct pathogen isolation from mesenteric lymph nodes (MLN). This procedure is considered the most reliable for diagnosing salmonellosis in apparently healthy pigs. The presence of simultaneous infections by different Salmonella strains in the same animal has never been reported and could have important epidemiological implications.

RESULTS

Fourteen finishing pigs belonging to 14 farms that showed high salmonellosis prevalence and a variety of circulating Salmonella strains, were found infected by Salmonella spp, and 7 of them were simultaneously infected with strains of 2 or 3 different serotypes. Typhimurium isolates showing resistance to several antimicrobials and carrying mobile integrons were the most frequently identified in the colonized MLN. Four animals were found infected by Salmonella spp. of a single serotype (Rissen or Derby) but showing 2 or 3 different antimicrobial resistance profiles, without evidence of mobile genetic element exchange in vivo.

CONCLUSION

This is the first report clearly demonstrating that pigs naturally infected by Salmonella may harbour different Salmonella strains simultaneously. This may have implications in the interpretation of results from baseline studies, and also help to better understand human salmonellosis outbreaks and the horizontal transmission of antimicrobial resistance genes.

The experience of caregiving: the influence of coping strategies on behavioral and psychological symptoms in patients with Alzheimer's disease

OBJECTIVES

To determine whether caregiver coping strategies are independently associated with behavioral and psychological symptoms (BPS) in Alzheimer's disease (AD) after accounting for patient characteristics.

METHODS

Cross-sectional data analysis of 80 patients with AD and their primary caregivers. The presence of BPS was recorded using the Neuropsychiatric Inventory (NPI). The relationship between caregiver characteristics and BPS was assessed through one-way analysis of variance, two-tailed student t-tests or correlation coefficients. Multivariate linear regression was used to determine the combined effect of all caregiver factors that were significant on bivariate analysis regarding coping and BPS controlling for patient characteristics.

RESULTS

Caregivers were on average 62 years old, 77% female, and most were the children or the spouse of the patient. Over 50% had significant depression or anxiety. Patients were on average 77 years old and 62% were female, and most had moderate to severe dementia. After adjusting for patient characteristics, patients cared for by more depressed, more burdened, or those using more disengagement coping strategies showed higher NPI mean composite scores.

CONCLUSION

Coping strategies are associated with BPS regardeless of patient characteristics. Interventions to reduce BPS should focus on which psychological coping strategies caregivers use. Understanding how coping strategies influence BPS may help tailor specific interventions for caregivers.

The extradomain a of fibronectin enhances the efficacy of lipopolysaccharide defective Salmonella bacterins as vaccines in mice

The Extradomain A from fibronectin (EDA) has an immunomodulatory role as fusion protein with viral and tumor antigens, but its effect when administered with bacteria has not been assessed. Here, we investigated the adjuvant effect of EDA in mice immunizations against Salmonella enterica subspecies enterica serovar Enteritidis (Salmonella Enteritidis). Since lipopolysaccharide (LPS) is a major virulence factor and the LPS O-polysaccharide (O-PS) is the immunodominant antigen in serological diagnostic tests, Salmonella mutants lacking O-PS (rough mutants) represent an interesting approach for developing new vaccines and diagnostic tests to differentiate infected and vaccinated animals (DIVA tests). Here, antigenic preparations (hot-saline extracts and formalin-inactivated bacterins) from two Salmonella Enteritidis rough mutants, carrying either intact (SEΔwaaL) or deep-defective (SEΔgal) LPS-Core, were used in combination with EDA. Biotinylated bacterins, in particular SEΔwaaL bacterin, decorated with EDAvidin (EDA and streptavidin fusion protein) improved the protection conferred by hot-saline or bacterins alone and prevented significantly the virulent infection at least to the levels of live attenuated rough mutants. These findings demonstrate the adjuvant effect of EDAvidin when administered with biotinylated bacterins from Salmonella Enteritidis lacking O-PS and the usefulness of BEDA-SEΔwaaL as non-live vaccine in the mouse model.

The extradomain A of fibronectin (EDA) combined with poly(I:C) enhances the immune response to HIV-1 p24 protein and the protection against recombinant Listeria monocytogenes-Gag infection in the mouse model

The development of effective vaccines against HIV-1 infection constitutes one of the major challenges in viral immunology. One of the protein candidates in vaccination against this virus is p24, since it is a conserved HIV antigen that has cytotoxic and helper T cell epitopes as well as B cell epitopes that may jointly confer enhanced protection against infection when used in immunization-challenge approaches. In this context, the adjuvant effect of EDA (used as EDAp24 fusion protein) and poly(I:C), as agonists of TLR4 and TLR3, respectively, was assessed in p24 immunizations using a recombinant Listeria monocytogenes HIV-1 Gag proteins (Lm-Gag, where p24 is the major antigen) for challenge in mice. Immunization with EDAp24 fusion protein together with poly(I:C) adjuvant induced a specific p24 IFN-γ production (Th1 profile) as well as protection against a Lm-Gag challenge, suggesting an additive or synergistic effect between both adjuvants. The combination of EDA (as a fusion protein with the antigen, which may favor antigen targeting to dendritic cells through TLR4) and poly(I:C) could thus be a good adjuvant candidate to enhance the immune response against HIV-1 proteins and its use may open new ways in vaccine investigations on this virus.

Disengagement coping partially mediates the relationship between caregiver burden and anxiety and depression in caregivers of people with Alzheimer's disease. Results from the MÁLAGA-AD study

BACKGROUND

Caring for people with Alzheimer's disease can be considered stressful and demand adjustment strategies. While various variables have been associated with caregiver anxiety and depression, a possible mediator role of coping strategies adopted by caregivers between caregiver burden and anxiety and depression is still unclear. We hypothesized that caregivers with clinically significant anxiety and depression were more likely to use disengagement coping strategies that non-anxious and non-depressed caregivers.

METHODS

This study involved 80 Alzheimer disease patients and their primary caregivers. Patients were evaluated using the Mini Mental State Examination, the Bayer Activities of Daily Living Scale, the Global Deterioration Scale and the Neuropsychiatric Inventory. Caregivers were evaluated with the Caregiver Burden Interview, the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Coping Strategies Inventory. We conducted a series of multiple linear regressions to determine the relationship between caregiver burden and caregiver anxiety and depression, and if the coping strategies mediated this relationship.

RESULTS

Using more disengagement (β=0.270, p<0.001) and less engagement coping (β=-0.310, p<0.001) were predictors for anxiety scores. Using more disengagement (β=0.250, p<0.001) and less engagement coping (β=-0.261, p<0.001) were predictors for depression scores.

LIMITATIONS

This study was a cross-sectional design, so the direction of causality should be strengthened by a longitudinal study.

CONCLUSIONS

Most caregivers reported higher anxiety and depression levels and this was partially mediated by their dysfunctional coping strategies.

Salmonellosis in finishing pigs in Spain: prevalence, antimicrobial agent susceptibilities, and risk factor analysis

A herd-based survey of Salmonella in pigs was carried in a major pig producing region of Spain. Mesenteric lymph nodes were collected from the carcasses of 25 pigs from each of 80 herds at time of slaughter. Salmonella spp. were isolated from 31% of animals and 94% of herds. Within-herd prevalence ranged from 4 to 88%, with the prevalence in most herds being greater than 10%. A large diversity of Salmonella serotypes was found, with Typhimurium, 4,[5],12:i:-, and Rissen being the most prevalent. Two or more serotypes coexisted in 73% of the herds. Salmonella Typhimurium was present in 68% of the herds. Most (82%) of the Salmonella isolates belonged to serogroups targeted by enzyme-linked immunosorbent assay tests for pig salmonellosis. Resistance to at least one antimicrobial agent was detected in 73% of the strains, and one or more resistant strains were recovered from pigs in 93% of the herds. Antimicrobial agent resistance (AR) was more frequent among the most prevalent than it was among the rarer serotypes. Twenty-five multi-AR patterns were found. Resistance to three or more families of antimicrobial agents was found in 75% of AR strains. The finding that many of the herds yielded isolates of several multi-AR patterns indicates that Salmonella infections were acquired from multiple sources. High prevalence of Salmonella in herds was associated with lack of rodent control programs, herds from farms with only finishing pigs, herds managed by more than one full-time worker, herds for which the source of drinking water was not a city supply, and relatively long fattening times.

Surveillance of listeriosis in Navarre, Spain, 1995-2005--epidemiological patterns and characterisation of clinical and food isolates

We monitored the incidence of human listeriosis in Navarre, a region in north of Spain between 1995 and 2005, and carried out the characterisation of Listeria monocytogenes isolates obtained from clinical samples and ready-to-eat products (sliced cooked meat, smoked salmon and liver pate). The active surveillance requesting hospitals to notify all listeriosis cases (n=40) yielded higher incidence rates (average annual rate 0.65/100,000 inhabitants, range 0.18-1.18/100,000 inhabitants) than expected. Pregnant women were the largest group affected (n=13, 32.5% of the cases), with a peak in incidence during the last three years of the study period. From the 40 human cases we obtained 33 Listeria isolates. Serological and molecular characterisation by PFGE identified 20 different pulsotypes, which on three occasions enabled us to link sporadic cases into clusters. Although we could not identify the incriminated food product we found two clinical pulsotypes among smoked salmon and cooked meat isolates. Surveillance of listeriosis in Spain should be improved and coordinated with other European Union Member States in order to better estimate the burden of disease and to prevent foodborne outbreaks.

Surveillance of listeriosis in Navarre, Spain, 1995-2005 – epidemiological patterns and characterisation of clinical and food isolates

We monitored the incidence of human listeriosis in Navarre, a region in north of Spain between 1995 and 2005, and carried out the characterisation of Listeria monocytogenes isolates obtained from clinical samples and ready-to-eat products (sliced cooked meat, smoked salmon and liver pate). The active surveillance requesting hospitals to notify all listeriosis cases (n=40) yielded higher incidence rates (average annual rate 0.65/100,000 inhabitants, range 0.18-1.18/100,000 inhabitants) than expected. Pregnant women were the largest group affected (n=13, 32.5% of the cases), with a peak in incidence during the last three years of the study period. From the 40 human cases we obtained 33 Listeria isolates. Serological and molecular characterisation by PFGE identified 20 different pulsotypes, which on three occasions enabled us to link sporadic cases into clusters. Although we could not identify the incriminated food product we found two clinical pulsotypes among smoked salmon and cooked meat isolates. Surveillance of listeriosis in Spain should be improved and coordinated with other European Union Member States in order to better estimate the burden of disease and to prevent foodborne outbreaks.

Management of hepatic venous obstruction after split-liver transplantation

Stenosis of the hepatic vein anastomosis is an unusual but critical complication after liver transplantation. In pediatric liver transplantation, the scarcity of size-matched donors has required the use of segmental liver allografts, either as reduced-size or split-liver grafts. This report illustrates the primary use of a hepatic vein stent to manage hepatic venous outflow obstruction in a pediatric split-liver recipient, and reviews experience in the management of hepatic venous outflow obstruction after liver transplant using stent methods.

[Paracentesis associated to dextran-70 in the treatment of ascites in patients with chronic liver diseases: a randomized therapeutic study]

The treatment of ascites of large volume in chronic liver disease patients was evaluated in the present study. We compared diuretics with paracentesis and an infusion of Dextran-70. Therapeutic efficacy, complications and length of hospital stay were the variables studied. Of the 38 patients, 20 were selected randomly. They were evaluated using clinical, laboratory and/or histological criteria: 10 patients in the paracentesis group with Dextran-70 and 10 in the diuretic group. The groups were similar with respect to age, diagnosis and Child-Pugh classification. However, there was a greater number of males in the paracentesis group with Dextran-70. In each paracentesis, an average of 9.41 liters (4.5 to 14.1) of ascitic fluid was collected. The average hospitalization period in the paracentesis group with Dextran-70 was 10.5 days (8-14), significantly less when compared to the diuretic group: 24.4 days (14-48). In the diuretic group one patient presented complications such as hyperkalemia, increased urea and creatinine levels, while in the paracentesis group with Dextran-70 one patient presented a temperature above 38 degrees C during treatment. The results suggest that paracentesis associated with Dextran-70 could be a therapeutic alternative for chronic liver disease patients with ascites in our population. It was effective; it had no significant side effects; it reduced the length of hospital stay and therefore should decrease the cost and the risk of complications in patients requiring prolonged hospitalization periods.

Ultrasonography is more effective than computed tomography in excluding invasion of the carotid wall by cervical lymphadenopathies

Twelve patients with head and neck cancer, bulky lymphadenopathies, and clinical suspicion of carotid artery infiltration, had preoperative CT and US. The results of both techniques were correlated with surgical findings (one case of invasion and 11 of non-invasion), to evaluate the role of CT and US in the preoperative diagnosis of tumor invasion of the carotid wall. While CT showed a high level of failures (11 false positives and one true positive), US (one true positive, one false negative, and 10 true negatives) appears to be an easy and helpful method for predicting non-invasion of the carotid wall. However, the usefulness of US in detecting invasion cannot be evaluated, due to the limited number of positive cases.

HLA molecules in basal cell carcinoma of the skin

Fifty basal cell carcinomas (BCC) and 8 samples of healthy skin were studied for HLA class I and class II antigen expression and for the presence of mutations in codon 12 of the K-ras and H-ras genes. All samples of healthy skin and of epithelium near the tumor showed high levels of class I molecules, whereas 38% of the tumors showed complete absence. Sixty-two percent of the tumors presented positive class I expression with heterogeneous staining. These losses were due to the simultaneous lack of heavy chain and beta 2-microglobulin. Selective losses of HLA-A or HLA-B antigens were not detected. Class II antigens were absent in most of the tumors, only two tumors showing a few weakly positive cells with anti-HLA-DR mAb. The loss of class I expression correlated significantly with the degree of histological differentiation and aggressiveness. We were unable to correlate class I expression with clinical size, depth of invasion or the extent of leukocytic infiltrate surrounding the tumor. Analysis by PCR amplification of codon 12 of the K-ras and H-ras oncogenes detected H-ras mutations in 1 out of 50 cases, and no K-ras mutations in any of the tumors studied. Thus, a positive relationship between K-ras and H-ras mutations and BCC tumorigenesis or MHC alterations seems unlikely in this neoplasia.

[Changes in blood calcium during liver transplant in children]

We have evaluated the changes in plasma total and ionic calcium levels in twenty hepatic transplantations in pediatric patients. Direct intraoperative monitoring of ionic calcium is fundamental, because its variability is unrelated with total calcium levels; in addition, normal ionic calcium levels contribute to the hemodynamic stability of the patient. Although at the end of the operation total and ionic calcium levels were similar to the postinduction measurement, their values were dissociated in the perianhepatic period. In the anhepatic phase ionic calcium reached its lowest value (1.00 mmol/l) although total calcium increased above postinduction level from 2.13 to 2.46 mmol/l (p less than 0.05). In hepatic transplantation in pediatric patients calcium administration is indicated during the transfusion of citrated blood, being particularly necessary during the anhepatic phase to prevent ionic hypocalcemia.