Characteristics, management, and outcome of pediatric patients with post-transplant lymphoproliferative disease-A 20 years' experience from Austria

BACKGROUND

Management of pediatric post-transplantation lymphoproliferative disorder (PTLD) after hematopoietic stem cell (HSCT) and solid organ transplantation (SOT) is challenging.

AIM

This study of 34 PTLD patients up to 19-years old diagnosed in Austria from 2000 to 2018 aimed at assessing initial characteristics, therapy, response, and outcome as well as prognostic markers of this rare pediatric disease.

METHODS AND RESULTS

A retrospective data analysis was performed. Types of allografts were kidney (n = 12), liver (n = 7), heart (n = 5), hematopoietic stem cells (n = 4), lungs (n = 2), multi-visceral (n = 2), small intestine (n = 1), and vessels (n = 1). Eighteen/34 were classified as monomorphic PTLD, with DLBCL accounting for 15 cases. Polymorphic disease occurred in nine, and non-destructive lesions in six cases. One patient had a non-classifiable PTLD. Thirteen/34 patients are surviving event-free in first remission (non-destructive, n = 4/6; polymorphic, n = 4/9; monomorphic, n = 6/18). Fourteen/34 patients lacked complete response to first-line therapy, of whom seven died. Four/34 patients relapsed, of whom two died. In 3/34 patients, death occurred as a first event. The 5-year overall and event-free survival rates were 64% ± 9% and 35% ± 9% for the whole cohort. Among all parameters analyzed, only malignant disease as the indication for transplantation had a significantly poor influence on survival.

CONCLUSIONS

This study shows PTLD still to be a major cause of mortality following SOT or HSCT in children. A continued understanding of the molecular biology of the disease shall allow to decrease treatment intensity for lower risk patients and to identify patients who may benefit from newer therapy approaches to improve outcome and decrease morbidity.

Development and validation of the paediatric Carbohydrate Perception Questionnaire (pCPQ), an instrument for the assessment of carbohydrate-induced gastrointestinal symptoms in the paediatric population

BACKGROUND

There is an unmet need for a validated, test-specific symptom questionnaire to evaluate carbohydrate perception during breath tests. Our aim was to develop and validate a questionnaire for the assessment of symptoms after a provocative carbohydrate load.

METHODS

After a literature search and initial focus group-style interviews, five relevant complaints were identified. Responses were given on a Likert-type faces scale with a language children use and understand. Reliability, validity and responsiveness to change were established by the implementation of the questionnaire during breath tests in 215 pediatric subjects. Correlation between the questionnaire and a medical interview by a pediatrician who was blinded to the results of the questionnaire (n = 19) was determined.

KEY RESULTS

The questionnaire had good face and content validity (Lawshe ratio = 1). Intraclass correlation coefficients for test-retest reliability (n = 116) demonstrated good repeatability (P < .001), and effect sizes were small (Cohen's d < 0.15 for all symptoms). Convergent validity and discriminant validity were supported according to the multitrait-multimethod matrix method. The results obtained by the questionnaire correlated highly with the result of the medical interview (P < .001; Fisher's exact test). Cronbach's alpha was 0.81. Responsiveness was verified for the whole patient group and subgroups with medium to high effect sizes.

CONCLUSIONS AND INFERENCES

The paediatric Carbohydrate Perception Questionnaire (pCPQ) is a simple, test-specific questionnaire for a pediatric population. It is a valid instrument with excellent psychometric properties to assess gastrointestinal symptoms after carbohydrate ingestion. The pCPQ can replace non-validated symptom assessment during carbohydrate breath tests and allows a standardized diagnosis of carbohydrate intolerance.

Options in extracorporeal support of multiple organ failure

Multiorgan failure is among the most frequent reasons of death in critically ill patients. Based on extensive and long-term use of renal replacement therapy, extracorporeal organ support became available for other organ failures. Initially, most of these techniques (e.g. extracorporeal membrane oxygenation, extracorporeal CO₂ removal [ECCO2R] and extracorporeal liver support) were used as stand-alone single organ support systems. Considering multiple interactions between native organs (“crosstalk”), combined or integrated extracorporeal organ support (ECOS) devices are intriguing. The concept of multiple organ support therapy (MOST) providing simultaneous and combined support for different failing organs was described more than 15 years ago by Ronco and Bellomo. This concept also implicates overcoming the “compartmentalized” approach provided by different single organ specialized professionals by a multidisciplinary and multiprofessional strategy. The idea of MOST is supported by the failure of several recent studies on single organ support including liver and lung support. Improvement of outcome by ECOS necessarily depends on optimized patient selection, integrated organ support and limitation of its side effects. This implicates challenges for engineers, industry and healthcare professionals. From a technical viewpoint, modular combination of pre-existing technologies such as renal replacement, albumin-dialysis, ECCO2R and potentially cytokine elimination can be considered as a first step. While this allows for stepwise and individual combination of standard organ support facilities, it carries the disadvantage of large extracorporeal blood volume and surfaces as well as additive costs. The more intriguing next step is an integrated platform providing the capacity of multiple organ support within one device. (This article is freely available.)

A retrospective clinical and microbial analysis of 32 patients with bilomas

BACKGROUND

Bilomas are defined collections of bile fluids mainly caused by iatrogenic injuries of the bile duct system. Owing to the infrequency of this disease, studies addressing bilomas are rare.

METHODS

By using an endoscopic database, this retrospective study identified 32 patients with bilomas treated between 2004 to 2015, in order to analyse aetiology, clinical presentation, spectrum of pathogens, and resolution rate of bilomas.

RESULTS

65.6% of the study population (21/32) developed bilomas after surgery and 21.9% (7/32) after endoscopic retrograde cholangiography (ERC). Icterus, fever, and abdominal pain were the leading symptoms. 93.9% (46/49) of microbiological bile cultures revealed a positive microbiology. The predominant microorganisms were the group of Enterobacteriaceae (43.0%, 52/121), followed by Enterococcus spp. (32.2%, 39/121), and Candida spp. (9.1%, 11/121). Multiresistant bacteria like Enterobacteriaceae were isolated from one quarter of all patients. Single or multimodal treatment resulted in an overall complication rate of 4.8% (9/188). Clinical follow-up analysis showed a complete resolution rate of 78.3% for interventional therapy and 80% in the non-interventional group.

CONCLUSIONS

Pathogen spectrum of bilomas mainly comprises the group of Enterobacteriacae and Enterococcus spp., with a high proportion of multiresistant bacteria. Different interventional approaches are available for biloma drainage, which seem to be safe and effective for most patients.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00015208 , retrospectively registered.

Physical Work Capacity in Chronic Renal Disease

We studied the physical fitness of 71 patients with renal disease before dialysis, after starting dialysis, and after successful renal transplantation. Maximal muscle strength was determined in 58 patients and maximal cardiovascular capacity was assessed in 36 patients. Before dialysis there was a 31 percent reduction in muscle strength in men and 47 percent in women. The loss of muscle strength was most pronounced in the leg extensors. Cardiovascular capacity and muscle strength was positively correlated in the dialysis patients (p ≤ 0.05). The cardiovascular capacity was decreased 29% in predialysis patients, 45% in dialysis patients and 37% in transplanted patients compared to untrained healthy controls. The predialysis patients had a 19% greater cardiovascular capacity than the dialysis patients and a 9% greater cardiovascular capacity than the transplanted patients. While hemoglobin concentrations showed a positive correlation (p ≤ 0.05) with maximal cardiovascular capacity and creatinine concentration showed a negative correlation (p ≤ 0.05) with maximal cardiovascular capacity in the predialysis patients, hemoglobin concentrations and creatinine concentrations did not correlate with cardiovascular capacity in the dialysed and transplanted patients. In dialysis patients as well as in patients after kidney transplantation hemoglobin and creatinine concentrations, muscle strength, height, weight, and age are factors influencing the physical work capacity, but none of these variables alone seems to be a strong determination factor. Besides the complications of kidney disease which may itself reduce physical fitness, the lack of physical training is an important factor in determining the residual muscle strength and cardiovascular capacity for all patients with renal insufficiency.

First description of spontaneous fungal peritonitis caused by Fusarium solani in a critically ill patient with liver cirrhosis

Fusarium spp., common soil moulds, are emerging fungal pathogens in immunocompromised subjects. We report the first case of Fusarium solani peritonitis in a patient with liver cirrhosis. Because of the high morbidity and mortality associated with fusariosis, an aggressive approach to treatment as well as identification of the species and drug susceptibilities is warranted.

Discovery of novel drug sensitivities in T-PLL by high-throughput ex vivo drug testing and mutation profiling

T-cell prolymphocytic leukemia (T-PLL) is a rare and aggressive neoplasm of mature T-cells with an urgent need for rationally designed therapies to address its notoriously chemo-refractory behavior. The median survival of T-PLL patients is <2 years and clinical trials are difficult to execute. Here we systematically explored the diversity of drug responses in T-PLL patient samples using an ex vivo drug sensitivity and resistance testing platform and correlated the findings with somatic mutations and gene expression profiles. Intriguingly, all T-PLL samples were sensitive to the cyclin-dependent kinase inhibitor SNS-032, which overcame stromal-cell-mediated protection and elicited robust p53-activation and apoptosis. Across all patients, the most effective classes of compounds were histone deacetylase, phosphoinositide-3 kinase/AKT/mammalian target of rapamycin, heat-shock protein 90 and BH3-family protein inhibitors as well as p53 activators, indicating previously unexplored, novel targeted approaches for treating T-PLL. Although Janus-activated kinase-signal transducer and activator of transcription factor (JAK-STAT) pathway mutations were common in T-PLL (71% of patients), JAK-STAT inhibitor responses were not directly linked to those or other T-PLL-specific lesions. Overall, we found that genetic markers do not readily translate into novel effective therapeutic vulnerabilities. In conclusion, novel classes of compounds with high efficacy in T-PLL were discovered with the comprehensive ex vivo drug screening platform warranting further studies of synergisms and clinical testing.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Analogiebetrachtungen und Analogrechner zur Behandlung der Korrelation von Π-Elektronen (1)

Um das Verhalten eines Moleküls bei Lichteinwirkung zu behandeln, wird die Annahme zugrunde gelegt, daß jedes π-Elektron im Feld der Lichtwelle, im Feld des Molekülrumpfs und im zeitlich veränderlichen gemittelten Feld aller übrigen π-Elektronen des Moleküls steht. Das sich so mit der zeitabhängigen SCHRÖDINGER-Gleichung ergebende Gleichungssystem ist analog zu dem System der Gleichungen, die das Verhalten einer Gesamtheit untereinander gekoppelter linearer klassischer Oszillatoren beschreibt, welche unter der Wirkung einer periodisch veränderlichen äußeren Kraft stehen. Das Gleichungssystem kann mit einem geeigneten Analogrechner leicht gelöst werden und das Verfahren ist daher auch im Fall komplizierter π-Elektronensysteme leicht durchführbar. Es zeigt sich, daß das Verfahren zu einer Näherung führt, wie sie in der Methode der Konfigurationswechselwirkung bei Mitberücksichtigung der zweifach angeregten Konfigurationen erreicht wird. Der Einfluß des Lösungsmittels auf die Größe des an den Elektronen wirksamen Feldes der Lichtwelle wird untersucht.

The use of proton pump inhibitors and the spectrum and number of biliary pathogens in patients with acute cholangitis

BACKGROUND

Knowledge of the bacterial spectrum for acute cholangitis is essential for adequate empiric antibiotic treatment.

AIM

To analyse the relation of proton pump inhibitors (PPI) with biliary pathogens in patients with acute cholangitis.

METHODS

This retrospective study identified 278 patients with 318 acute cholangitis episodes using an endoscopic database. The relationship between PPI and microbiological outcomes was assessed by logistic and poisson regression analysis for binary and count data.

RESULTS

In total, 882 pathogens were isolated, of which, 120 cholangitis episodes occurred with PPI; 198 cholangitis episodes without PPI. Multivariate poisson regression analysis showed that PPI use resulted in a 23% increase in the number of biliary pathogens [3.14 vs. 2.55 (Δ = 0.59), P < 0.01], whereas stent therapy, previous interventional procedures (endoscopic retrograde cholangiography/percutaneous transhepatic cholangiography), genesis, age and sex showed no significant association with the number of biliary pathogens. Significantly, more cholangitis episodes with more than one pathogen isolated occurred during PPI treatment [103/120 (86%) vs. 151/198 (76%), P = 0.04]. Analysis of intrinsic anti-microbial resistance patterns was performed: Anti-microbial combination therapies were significantly more required to cover all isolated pathogens in cholangitis episodes with PPI than in cholangitis episodes without PPI (44/120 vs. 46/198, P = 0.01). Additionally, PPI use was associated with a significantly higher incidence of oropharyngeal flora in the biliary tract (53/120 vs. 61/198, P = 0.02).

CONCLUSIONS

Proton pump inhibitors seem to influence biliary pathogens by increasing the number and broadening the spectrum of biliary pathogens. However, the findings of this hypothesis-generating study need to be tested by confirmatory studies.

[Early functional treatment of intra-articular fractures of the proximal interphalangeal joint of the finger using a modified traction device]

INTRODUCTION

Treatment of intra-articular fractures of the middle phalanx is both difficult and controversial. We report our experience of using a modified dynamic traction device (mTD) utilizing only one pin in the head of the middle phalanx and thus facilitating further open reconstructive surgery at the proximal interphalangeal joint (PIP). The pin does not necessarily have to be inserted in the movement axis of the joint.

AIM OF THE STUDY

The aim of the study was to a) determine the effectiveness of the mTD, particularly in comparison with other distraction systems used in the treatment of middle phalanx fractures as described in the literature, and b) compare the results of patients treated using an mTD only with the results of those treated with an mTD in combination with additional open reconstructive surgery.

PATIENTS AND METHODS

26 patients with a mean age of 37 years were treated for intra-articular fractures of the base of the middle phalanx using an mTD in the period between 2007 and 2011. 13 of these patients also underwent additional open reconstructive surgery. 18 of the 26 patients (69%) were reevaluated after 33 months (range 9-44 months); 10 of these had undergone additional open reconstructive surgery. Follow-up of 14 of the patients included their completion of a structured questionnaire and calculation of their DASH scores as well as radiological and clinical examinations. 4 patients completed the questionnaire and had their DASH score calculated. Measurement of range of motion was performed by the treating general practitioner. Patient records were analysed with a particular focus on complications and duration of therapy.

RESULTS

The mTD was used for an average of 34 days (range 8-53 days) and overall treatment took an average of 74 days (range 66-154 days). 4 pin tract infections were reported. The mean DASH score was 6.4. The mean range of motion in the PIP joint was 70° (range 30-110°). The range of motion of the PIP and DIP joints (61º) was significantly poorer in patients with additional surgery than that (82º) in patients with sole mTD treatment. Treatment with the mTD gave results similar to those obtained with other distraction devices with good subjective evaluation by the patients.

CONCLUSION

Dynamic traction with the help of the modified traction devices is suitable for treating intra-articular fractures of the proximal interphalangeal joint, as demonstrated by a comparison with the literature. Patients who underwent additional open surgery showed less favorable results. The present method has the advantage that only one wire needs to be inserted subcapitaly at a distance from the fracture in the middle finger and this facilitates further surgical interventions.