Anatomical classification and clinical outcomes of biliary strictures in living donor liver transplantation using right liver grafts.

This study aimed to classify the anatomical types of biliary strictures, including intrahepatic biliary stricture (IHBS), after living donor liver transplantations (LDLTs) using right liver grafts and evaluate their prognosis. Among 692 adult patients who underwent right liver LDLT, 198 recipients with biliary strictures (28.6%) were retrospectively reviewed. Based on data obtained during the first cholangiography, the patients' biliary strictures were classified into the following three types according to the levels and number of branches involved: Types 1 (anastomosis), 2 (second-order branch [a, one; b, two or more; c, extended to the third-order branch]), and 3 (whole graft [a, multifocal strictures; b, diffuse necrosis]). IHBS was defined as a nonanastomotic stricture. Among the 198 recipients with biliary strictures, the IHBS incidence rates were 38.4% ( n = 76). The most common type of IHBS was 2c ( n = 43, 56.6%), whereas Type 3 ( n = 10, 13.2%) was uncommon. The intervention frequency per year significantly differed among the types (Type 1, 2.3; Type 2a, 2.3; Type 2b, 2.8; Type 2c, 4.3; and Type 3, 7.2; p < 0.001). The intervention-free period for more than 1 year, which was as follows, also differed among the types: Type 1, 84.4%; Type 2a, 87.5%; Type 2b, 86.7%; Type 2c, 72.1%; and Type 3, 50.0% ( p = 0.048). The graft survival rates of Type 3 (80.0%) were significantly lower than those of the other types ( p = 0.001). IHBSs are relatively common in right liver LDLTs. Although Type 3 IHBSs are rare, they require more intensive care and are associated with poorer graft survival rates than anastomosis strictures and Type 2 IHBS.

Determining the Association Between the Origin of Sepsis and the Severity of Sepsis in Intensive Care Unit (ICU) Patients Using Acute Physiology and Chronic Health Evaluation (APACHE) IV.

Objective The objective of this study is to compare the outcomes of hospital mortality, the requirement of invasive ventilation, vasopressor requirement, duration of vasopressor requirement, and duration of intensive care unit (ICU) stay among the different causes of sepsis and to determine which cause of sepsis had the most severe outcomes. Methods A retrospective chart review was done in critically ill adult patients who were admitted with sepsis to the ICU from July 2017 until July 2019. Acute Physiology and Chronic Health Evaluation (APACHE) IV scores were calculated on patients admitted to ICU on day one of ICU admission. Each patient was then evaluated for outcomes of hospital mortality, need for invasive ventilation, requirement of vasopressors, duration of vasopressors, and duration of ICU stay. The outcomes were then compared between the different sources of sepsis to determine which source of sepsis had the highest severity. Results In total, 176 patients were included in the study. Ninety-three patients were admitted with respiratory sepsis, 26 patients were admitted with gastrointestinal sepsis, 31 patients were admitted with urosepsis, and 26 patients were admitted with other miscellaneous causes of sepsis. The hospital mortality was highest in the respiratory sepsis group at 32%, with a trend towards statistical significance with a P value of 0.057. ICU stay duration was highest in patients with respiratory sepsis at six days, with a statistically significant P value of < 0.001. The need for invasive ventilation was highest in patients with respiratory sepsis at 64%, with a statistically significant P value of < 0.001. The requirement of vasopressor support was highest in patients with respiratory sepsis at 47% and the duration of vasopressors was highest in both respiratory and gastrointestinal sepsis at three days, however, there was no statistical significance. Conclusion Among the different origins of sepsis, the patients with respiratory sepsis had the most severe outcomes, with the highest need for invasive ventilation and the highest ICU stay duration.

Determining the Need for Additional Testing With Quantiferon TB Gold in Patients With Positive Tuberculin Skin Tests and a History of BCG Vaccination.

OBJECTIVE:  To determine if the QuantiFERON-TB Gold (QFT) testing can be obviated for the diagnosis of latent tuberculosis infection (LTBI) in patients with a positive tuberculin skin test (TST) and a history of Bacillus Calmette-Guerin (BCG) vaccination by identifying high-risk features in patients with positive TST and a history of BCG vaccination who are associated with positive QFT. METHODS:  Retrospective chart review was done for 76 adult patients by dividing them into two groups. Group 1 consisted of true positive TST patients who had BCG vaccination and were positive for QFT. Group 2 consisted of false positive TST patients who had BCG vaccination but were negative for QFT. The two groups were compared to determine if the high-risk features of TST induration diameter of 15mm and more, TST induration of 20mm and more, recent immigration to the US, the advanced age of more than 65 years, country of origin with high TB burden, known exposure to active TB, and smoking history were more prevalent in Group 1 compared to Group 2. RESULTS:  Group 1 had 23 patients and Group 2 had 53 patients. Group 1 had a higher prevalence of patients with PPD induration of more than 10mm than Group 2, which was statistically significant with a P value of 0.03. Other risk factors of advanced age, exposure to active TB and smoking did not show statistically significant differences between Groups 1 and 2.  Conclusion: This study also confirms that if the TST induration is more than 10mm in patients with a history of BCG vaccination, the TST induration is likely because of LTBI and is less likely because of cross-reaction with BCG vaccination.

Right ventricular systolic pressure - Non-invasive bedside predictor of mortality and readmission in heart failure with reduced and preserved ejection fraction hospitalization.

OBJECTIVE: To study the prognostic role of right ventricular systolic pressure (RVSP) in patients with heart failure (HF). BACKGROUND: Although RVSP is a readily available echocardiographic parameter, it is often underused. Its prognostic role in patients with heart failure is not well established compared with pulmonary artery pressure measured by right heart catheterization. METHODS: This single-center retrospective cohort study included patients with acute heart failure hospitalization admitted to the hospital from January 2005 to December 2018. The primary predictor was right ventricular systolic pressure (RVSP) obtained from bedside transthoracic echocardiography at admission. We divided RVSP into two groups, RVSP <40 mm Hg (reference group) and RVSP ≥40 mm Hg. Primary outcome was all-cause mortality. Secondary outcomes were all-cause readmission and cardiac readmission. We conducted propensity-score matching and applied cox-proportional hazard model to compute hazard ratio (HR) with 95% confidence interval (CI). RESULTS: Out of 972 HF patients, 534 patients had RVSP <40 mm Hg and 438 patients had RVSP ≥40 mm Hg. Patients with RVSP ≥40 mm Hg compared with RVSP <40 mm Hg were associated with higher rates of death [HR: 1.60, 95% CI: 1.22-2.09, P-value = 0.001], all-cause readmissions [HR: 1.37, 95% CI: 1.09-1.73, P-value = 0.008] and cardiac readmissions [HR: 1.41, 95% CI: 1.07-1.85, P-value = 0.014]. CONCLUSION: Higher RVSP (≥40 mm Hg) in HF patients was associated with higher rates of death, all-cause readmissions, and cardiac readmissions. RVSP can be considered as a prognostic marker for mortality and readmission.

Absolute lymphocyte count as a predictor of mortality and readmission in heart failure hospitalization.

Background: There is renewed interest in pursuing frugal and readily available laboratory markers to predict mortality and readmission in heart failure. We aim to determine the relationship between absolute lymphocyte count (ALC) and clinical outcomes in patients with heart failure hospitalization. Methods: This was a retrospective cohort study of patients with heart failure. Patients were divided into two groups based on ALC, less than or equal to 1500 cells/mm3 and > 1500 cells/ mm3. The primary outcome was all-cause mortality. We did subgroup analysis based on ejection fraction and studied the association between ALC categories and clinical outcomes. Both ALC groups are matched by propensity score, outcomes were analyzed by Cox regression, and estimates are presented in hazard ratios (HR) and 95% confidence intervals (CI). Results: We included 1029 patients in the pre-matched cohort and 766 patients in the propensity-score matched cohort. The median age was 64 years (IQR, 54-75), and 60.78% were male. In the matched cohort, ALC less than or equal to 1500 cells/mm3 had a higher risk of mortality compared with ALC > 1500 cells/mm3 (HR 1.51, 95% CI: 1.17-1.95; P = 0.002). These results were reproducible in subgroups of heart failure. When ALC was divided into four groups based on their levels, the lowest group of ALC had the highest risk of mortality. Conclusions: In patients with heart failure and both subgroups, ALC less than or equal to 1500 cells/mm3 had a higher risk of mortality. Patients in lower groups of the ALC categories had a higher risk of mortality.

Intestinal Tuberculosis: A Diagnostic Challenge.

Diagnosing intestinal tuberculosis (TB) with uncommon clinical manifestations is often challenging. Here, we report a case of an alcoholic patient who presented with vague symptoms and was later diagnosed with intestinal TB. This patient experienced multiorgan failure causing hemodynamic instability requiring ionotropic support; acute hypoxic respiratory failure managed with non-invasive positive pressure ventilation, hepatic failure, transudative peritoneal effusion, and transudative pleural effusion. These conditions clouded our judgment to pursue colonoscopy for a definite diagnosis and delayed the anti-tuberculosis treatment. When intestinal tuberculosis TB is suspected, the differential diagnosis must be established with other gastrointestinal involving diseases, including mycobacterium avium complex (MAC) and Crohn's disease (CD). MAC can show overlapping features with intestinal TB or coexist with it; Acid-fast stain and tissue culture are the key tests to differentiate these two. In the presence of diagnostic uncertainty between intestinal TB and CD, a therapeutic trial with anti-tuberculous therapy may be warranted.

Hemidiaphragmatic Paralysis Post Stroke Leading to Hypercapneic Respiratory Failure.

Unilateral diaphragmatic paralysis is a rare complication after stroke. We report a case of right-sided hemidiaphragmatic paralysis after stroke in a 51-year-old man who presented with shortness of breath and orthopnea. Chest X-ray (CXR) revealed an elevated right-sided hemidiaphragm. The weakened diaphragmatic contraction from paralyzed right hemidiaphragm resulted in persistent atelectasis of the right lung base and inadequate alveolar ventilation leading to the development of right basal pneumonia with hypercapneic respiratory failure. However, the patient had a remarkable improvement with the appropriate institution of non-invasive ventilation and medical management with intravenous antibiotics.

Single Cell Analysis of Stored Red Blood Cells Using Ultra-High Throughput Holographic Cytometry.

Holographic cytometry is introduced as an ultra-high throughput implementation of quantitative phase imaging of single cells flowing through parallel microfluidic channels. Here, the approach was applied for characterizing the morphology of individual red blood cells during storage under regular blood bank conditions. Samples from five blood donors were examined, over 100,000 cells examined for each, at three time points. The approach allows high-throughput phase imaging of a large number of cells, greatly extending our ability to study cellular phenotypes using individual cell images. Holographic cytology images can provide measurements of multiple physical traits of the cells, including optical volume and area, which are observed to consistently change over the storage time. In addition, the large volume of cell imaging data can serve as training data for machine-learning algorithms. For the study here, logistic regression was used to classify the cells according to the storage time points. The analysis showed that at least 5000 cells are needed to ensure accuracy of the classifiers. Overall, results showed the potential of holographic cytometry as a diagnostic tool.

Efficacy of corticosteroids in non-intensive care unit patients with COVID-19 pneumonia from the New York Metropolitan region.

INTRODUCTION: The role of systemic corticosteroid as a therapeutic agent for patients with COVID-19 pneumonia is controversial. OBJECTIVE: The purpose of this study was to evaluate the effect of corticosteroids in non-intensive care unit (ICU) patients with COVID-19 pneumonia complicated by acute hypoxemic respiratory failure (AHRF). METHODS: This was a single-center retrospective cohort study, from 16th March, 2020 to 30th April, 2020; final follow-up on 10th May, 2020. 265 patients consecutively admitted to the non-ICU wards with laboratory-confirmed COVID-19 pneumonia were screened for inclusion. 205 patients who developed AHRF (SpO2/FiO2 ≤ 440 or PaO2/FiO2 ≤ 300) were only included in the final study. Direct admission to the Intensive care unit (ICU), patients developing composite primary outcome within 24 hours of admission, and patients who never became hypoxic during their stay in the hospital were excluded. Patients were divided into two cohorts based on corticosteroid. The primary outcome was a composite of ICU transfer, intubation, or in-hospital mortality. Secondary outcomes were ICU transfer, intubation, in-hospital mortality, discharge, length of stay, and daily trend of SpO2/FiO2 (SF) ratio from the index date. Cox-proportional hazard regression was implemented to analyze the time to event outcomes. RESULT: Among 205 patients, 60 (29.27%) were treated with corticosteroid. The mean age was ~57 years, and ~75% were men. Thirteen patients (22.41%) developed a primary composite outcome in the corticosteroid cohort vs. 54 (37.5%) patients in the non-corticosteroid cohort (P = 0.039). The adjusted hazard ratio (HR) for the development of the composite primary outcome was 0.15 (95% CI, 0.07-0.33; P <0.001). The adjusted hazard ratio for ICU transfer was 0.16 (95% CI, 0.07 to 0.34; P < 0.001), intubation was 0.31 (95% CI, 0.14 to 0.70; P- 0.005), death was 0.53 (95% CI, 0.22 to 1.31; P- 0.172), composite of death or intubation was 0.31 (95% CI, 0.15 to 0.66; P- 0.002) and discharge was 3.65 (95% CI, 2.20 to 6.06; P<0.001). The corticosteroid cohort had increasing SpO2/FiO2 over time compared to the non-corticosteroid cohort who experience decreasing SpO2/FiO2 over time. CONCLUSION: Among non-ICU patients hospitalized with COVID-19 pneumonia complicated by AHRF, treatment with corticosteroid was associated with a significantly lower risk of the primary composite outcome of ICU transfer, intubation, or in-hospital death, composite of intubation or death and individual components of the primary outcome.

McConnell's Sign Still Holds Its Value: A Lesson Learned from Two Cases.

Acute pulmonary embolism (PE) can be potentially fatal if not diagnosed and treated early. Mortality in untreated cases can be as high as 30%. Atypical presentation and submassive PE can be missed due to subtle clinical features. Computerized tomography pulmonary angiogram is expensive, exposes to radiation and carries the risk of contrast nephropathy or anaphylactic reactions. On the contrary, McConnell's sign, which is a highly specific sign of PE, can be demonstrated at the bedside with a transthoracic echocardiogram (TTE). Here we discuss two cases where bedside TTE demonstrating McConnell's sign helped in the diagnosis and treatment of PE.

Phase-sensitive OCT imaging of multiple nanoparticle species using spectrally multiplexed single pulse photothermal excitation.

We apply phase-sensitive optical coherence tomography to image multiple nanoparticle species with two excitation wavelengths matched to their distinct absorption peaks. Using different modulation frequencies, multiple species collocated within the sample can be distinguished. In addition, we characterize single-pulse excitation schemes as a method to minimize bulk heating of the sample. We demonstrate this new scheme with B-mode photothermal measurements of tissue phantoms.