Dysbiosis in early sepsis can be modulated by a multispecies probiotic: a randomised controlled pilot trial.

The gut is hypothesised to play an important role in the development and progression of sepsis. It is however unknown whether the gut microbiome and the gut barrier function is already altered early in sepsis development and whether it is possible to modulate the microbiome in early sepsis. Therefore, a randomised, double blind, placebo-controlled pilot study to examine the alterations of the microbiome and the gut barrier in early sepsis and the influence of a concomitant probiotic intervention on dysbiosis at this early stage of the disease was conducted. Patients with early sepsis, defined as fulfilling the sepsis definition from the 2012 Surviving Sepsis Campaign guidelines but without signs of organ failure, received multispecies probiotic (Winclove 607 based on Omnibiotic® 10 AAD) for 28 days. Gut microbiome composition, function, gut barrier and bacterial translocation were studied. Patients with early sepsis had a significantly lower structural and functional alpha diversity, clustered differently and showed structural alterations on all taxonomic levels. Gut permeability was unaltered but endotoxin, endotoxin binding proteins and peptidoglycans were elevated in early sepsis patients compared to controls. Probiotic intervention successfully increased probiotic strains in stool and led to an improvement of functional diversity. Microbiome composition and function are altered in early sepsis. Probiotic intervention successfully modulates the microbiome and is therefore a promising tool for early intervention in sepsis.

Soluble CD163 and soluble mannose receptor predict survival and decompensation in patients with liver cirrhosis, and correlate with gut permeability and bacterial translocation.

BACKGROUND: Activated hepatic macrophages play a key role in inflammation and fibrosis progression in chronic liver disease. AIM: To assess the prognostic value of soluble (s)CD163 and mannose receptor (sMR) in cirrhotic patients and explore associations with markers of intestinal permeability (lactulose-mannitol ratio, diamine oxidase), bacterial translocation (endotoxin, lipopolysaccharide-binding protein) and markers of systemic immune activation (interleukin-6, interleukin-8, sCD14). METHODS: We prospectively investigated 101 cirrhotic patients (Child-Pugh class A: n = 72, Child-Pugh classes B and C: n = 29) and 31 healthy controls. Patients were observed for a median follow-up of 37 months. RESULTS: Median plasma levels of sCD163 and soluble mannose receptor were significantly elevated in cirrhotic patients (P < .001) and increased with disease severity (sCD163 in healthy controls = 1.3, Child-Pugh class A = 4.2, Child-Pugh classes B and C = 8.4 mg/L; sMR in healthy controls = 15.8, Child-Pugh class A = 36.5, Child-Pugh classes B and C = 66.3 µg/dL). A total of 21 patients died during the observation period. Patients with sCD163 levels above 5.9 mg/L showed significantly reduced survival (survival rate after 36 months: 71% versus 98%, P < .001). Patients with soluble mannose receptor levels above 45.5 µg/dL developed significantly more complications of cirrhosis within 12 months (73% versus 9%, P < .001). Furthermore, both variables correlated with the lactulose-mannitol ratio, diamine oxidase, lipopolysaccharide and interleukin-8. CONCLUSION: Our data demonstrate the prognostic value of sCD163 in predicting long-term survival in patients with liver cirrhosis and identify soluble mannose receptor as a prognostic marker for occurrence of cirrhosis-associated complications. The correlation between gut barrier dysfunction and activation of macrophages points towards a link between them.

Randomised clinical trial: the effects of a multispecies probiotic vs. placebo on innate immune function, bacterial translocation and gut permeability in patients with cirrhosis.

BACKGROUND: Probiotics may correct intestinal dysbiosis and proinflammatory conditions in patients with liver cirrhosis. AIM: To test the effects of a multispecies probiotic on innate immune function, bacterial translocation and gut permeability. METHODS: In a randomised, double blind, placebo-controlled study, stable cirrhotic out-patients either received a daily dose of a probiotic powder containing eight different bacterial strains (Ecologic Barrier, Winclove, Amsterdam, The Netherlands) (n = 44) or a placebo (n = 36) for 6 months and were followed up for another 6 months. RESULTS: We found a significant but subclinical increase in neutrophil resting burst (2.6-3.2%, P = 0.0134) and neopterin levels (7.7-8.4 nmol/L, P = 0.001) with probiotics but not with placebo. Probiotic supplementation did not have a significant influence on neutrophil phagocytosis, endotoxin load, gut permeability or inflammatory markers. Ten severe infections occurred in total; one during intervention in the placebo group, and five and four after the intervention has ended in the probiotic and placebo group, respectively. Liver function showed some improvement with probiotics but not with placebo. CONCLUSIONS: Probiotic supplementation significantly increased serum neopterin levels and the production of reactive oxygen species by neutrophils. These findings might explain the beneficial effects of probiotics on immune function. Furthermore, probiotic supplementation may be a well-tolerated method to maintain or even improve liver function in stable cirrhosis. However, its influence on gut barrier function and bacterial translocation in cirrhotic patients is minimal.

Ventral incisional hernia (VIH) repair after liver transplantation (OLT) with a biological mesh: experience in 3 cases.

BACKGROUND: Hernias after orthotopic liver transplant (OLT) occur in about 30 % of cases. Predisposing factors in liver cirrhotic patients of cases are ascites, low abdominal muscle mass and cachexia before and immunosuppression after OLT. Standard operative transplant-technique even in small hernias is to implant a mesh. For patients after liver transplantation a porcine non-cross linked biological patch being less immunogenic than synthetic and cross-linked meshes is chosen for ventral incisional hernia repair. METHODS: 3 patients (1 female, 2 male), OLT indications Hepatitis C, exogenous- toxic cirrhosis, median-age 53 (51 - 56) and median time to hernia occurrence after OLT were 10 month (6 - 18 m) are documented. 2 patients suffered from diabetes, 2 from chronic-obstructive lung disease. Maintenance immunosuppressions were Everolimus in 1 patient, Everolimus + MMF in the second and Everolimus +Tacrolimus in the third patient. The biological was chosen for hernia repair due to the preexisting risk- factors. Meshes, 10 × 16 cm were placed, in IPOM (Intra-Peritonel-Onlay-Mesh) -position by relaparatomy. Insolvable, monofile, interrupted sutures were used. RESULTS: All patients recovered primarily, and were dismissed within 10 d post OP. No wound healing disorders or signs of postoperative infections occurred. All are free of hernia recurrence in a mean observation time of 22 month (10 - 36). CONCLUSION: The usage of porcine non-cross-linked biological patches seems feasible for incisional hernia repair after OLT. Wound infections in these patients have been observed with other meshes. Further investigation is needed to prove potential superiority of this biological to the other meshes.

Direct comparison of regulators of calcification between bone and vessels in humans.

Calcification is not only physiologically present in bone but is a main pathophysiological process in vasculature, favouring cardiovascular diseases. Our aim was to investigate changes in the expression of calcification regulators during vascular calcification in bone and vasculature. Levels of gene expression of osteoprotegerin (OPG), receptor activator of NF-κB ligand (RANKL), osteopontin (OPN), matrix gla protein (MGP), bone sialoprotein (BSP), SMAD6, and runt-related transcription factor 2 (RUNX2) were determined in bone, aorta, and external iliac artery tissue samples of transplant donors. Histological stages of atherosclerosis (AS) in vessels are defined as "no changes", "intima thickening", or "intima calcification". Patients' bone samples were subgrouped accordingly. We demonstrate that in vessels BSP and OPN expression significantly increased during intima thickening and decreased during intima calcification, whereas the expression of regulators of calcification did not significantly change in bone during intima thickening and intima calcification. At the stage of intima thickening, MGP, OPG, and SMAD6 expression and at stage of intima calcification only MGP expression was lower in bone than in vessel. The expression of BSP and RANKL was regulated in opposite ways in bone and vessels, whereas the expression of MGP, OC, RUNX2, and OPN was regulated in a tissue-specific manner. Our study is the first direct comparison of gene expression changes during AS progression in bone and vessels. Our results indicate that changes in the expression of regulators of calcification in the vessel wall as well as in bone occur early in the calcification process, even prior to deposition of calcium/phosphate precipitation.

Low incidence of coronary angiography in the evaluation process of the potential heart donor.

INTRODUCTION: We investigated the practice of coronary angiography (CA) on donor hearts. PATIENTS AND METHODS: Between January 1, 2000, and December 31, 2010, all reported organ donors aged <66 years were analyzed retrospectively. Donor charts were evaluated regarding a performed CA, its outcome, the timing of CA during the evaluation process, and reasons for organ refusal. The percentage of positive CA studies in organ donors aged ≥45 years was also evaluated. RESULTS: Of 292 reported organ donors, 152 organ donor hearts were declined (group 1), and 140 hearts (group 2) were transplanted. Of the 152 declined hearts, 91 hearts were found not suitable for organ offer, and 61 were not successfully allocated or were refused by Eurotransplant. CA was conducted in 17 organ donors (5.8%). In 6 donors, a previous CA was reported (all had pathologic findings), and in 11 donors, a donor CA was performed, indicating 4 pathologic and 7 negative findings (54.5% of the hearts evaluated by donor CA were transplanted). No complication or delay of the donation process was reportedly related to donor CA. CONCLUSIONS: Special emphasis and implementation of recommendations for CA to be part of the evaluation of donor organs seem necessary.

Socio-economic effects and cost saving potential of remote patient monitoring (SAVE-HM trial).

OBJECTIVE: In the SAVE-trial we evaluated the safety, reliability and improvements of patient management using the BIOTRONIK Home Monitoring®-System (HM) in pacemaker (PM) and implanted cardioverter defibrillator (ICD) patients. DESIGN: 115 PM (Module A) and 36 ICD-patients (Module B) were recruited 3 months after implantation. PATIENTS: 65 patients in Module A were randomised to HM-OFF and had one scheduled outpatient clinic follow-up(FU) per year, whereas patients randomised to HM-ON were equipped with the mobile transmitter and discharged without any further scheduled in-office FU. In Module B 18 patients were randomised to HM-OFF and followed by standard outpatient clinic controls every 6 months; 18 patients were randomised to HM-ON receiving remote monitoring plus one outpatient clinic visit per year; unscheduled follow-ups were performed when necessary. RESULTS: The average follow-up period was 17.1 ± 9.2 months in Module A and 26.3 ± 8.6 months in Module B. In both modules, the number of FUs per year was significantly reduced (Module A HM-ON 0.29 ± 0.6 FUs/year vs HM-OFF 0.53 ± 0.5 FUs/year; p b 0.001; Module B HM-ON 0.87 ± 0.25 vs HM-OFF 1.73 ± 0.53 FU/year,p b 0.001). Cost analysis was significantly lower in the HM-ON group compared to the HM-OFF group (18.0 ± 41.3 and 22.4 ± 26.9 € respectively; p b 0.003). 93% of the unscheduled visits in Module B were clinically indicated,whereas 55% of the routine FUs were classified as clinically unnecessary. CONCLUSION: Remote home monitoring of pacemaker and ICD devices was safe, reduced overall hospital visits, and detected events that mandated unscheduled visits.

Establishing a brain-death donor model in pigs.

INTRODUCTION: An animal model that imitates human conditions might be useful not only to monitor pathomechanisms of brain death and biochemical cascades but also to investigate novel strategies to ameliorate organ quality and functionality after multiorgan donation. METHODS: Brain death was induced in 15 pigs by inserting a catheter into the intracranial space after trephination of the skull and augmenting intracranial pressure until brain stem herniation. Intracranial pressure was monitored continuously; after 60 minutes, brain death diagnostics were performed by a neurologist including electroencephalogram (EEG) and clinical examinations. Clinical examinations included testing of brain stem reflexes as well as apnoe testing; then intensive donor care was performed according to standard guidelines until 24 hours after confirmation of brain death. Intensive donor care was performed according to standard guidelines for 24 hours after brain death. RESULTS: Sixty minutes after brain-death induction, neurological examination and EEG examination confirmed brain death. Intracranial pressure increased continuously, remaining stable after the occurrence of brain death. All 15 animals showed typical signs of brain death such as diabetes insipidus, hypertensive and hypotensive periods, as well as tachycardia. All symptoms were treated with standard medications. After 24 hours of brain death we performed successful multiorgan retrieval. DISCUSSION: Brain death can be induced in a pig model by inserting a catheter after trephination of the skull. According to standard guidelines the brain-death diagnosis was established by a flat-line EEG, which occurred in all animals at 60 minutes after induction.

Establishing a donation after cardiac death model in pigs.

INTRODUCTION: Due to the lack of human donors, several strategies have sought to expand the organ pool. Efforts to characterize donation after cardiac death (DCD) have included studies of cell viability, histological and immunohistochemical changes, and oxidative stress, which is known to negatively impact graft survival. A large animal model would be useful for these inquiries. Therefore, we sought to establish a DCD animal model in pigs. METHODS: We simulated non-heart-beating donation Maastricht II and III conditions in 24 pigs. Cardiac fibrillation was induced using 9-V direct current. After various times of ventricular fibrillation (1-10 minutes) with no mechanical and/or medical treatment to achieve cardiac output, reanimation was performed for 30 minutes prior to multiorgan donation. Then, a neurological status was performed. Blood samples were obtained at defined times tissue samples were stored in liquid nitrogen and subsequently embedded in paraffin and subjected to further analysis. RESULTS: We established a DCD pig model in our laboratory by inducing cardiac fibrillation. Up to now, only DCD donation according to the Maastricht criteria II and III has been performed, but establishing all Maastricht criteria of DCDs seems to be feasible. CONCLUSION: A DCD model in pigs enables us to characterize organ quality more precisely as well as evaluate amelioration of storage conditions and donor treatments in a large-animal model.

JTV519 (K201) reduces sarcoplasmic reticulum Ca²âº leak and improves diastolic function in vitro in murine and human non-failing myocardium.

BACKGROUND AND PURPOSE: Ca²âº leak from the sarcoplasmic reticulum (SR) via ryanodine receptors (RyR2s) contributes to cardiomyocyte dysfunction. RyR2 Ca²âº leak has been related to RyR2 phosphorylation. In these conditions, JTV519 (K201), a 1,4-benzothiazepine derivative and multi-channel blocker, stabilizes RyR2s and decrease SR Ca²âº leak. We investigated whether JTV519 stabilizes RyR2s without increasing RyR2 phosphorylation in mice and in non-failing human myocardium and explored underlying mechanisms. EXPERIMENTAL APPROACH: SR Ca²âº leak was induced by ouabain in murine cardiomyocytes. [Ca²âº]-transients, SR Ca²âº load and RyR2-mediated Ca²âº leak (sparks/waves) were quantified, with or without JTV519 (1 µmol·L⁻¹). Contribution of Ca²âº -/calmodulin-dependent kinase II (CaMKII) was assessed by KN-93 and Western blot (RyR2-Ser(2814) phosphorylation). Effects of JTV519 on contractile force were investigated in non-failing human ventricular trabeculae. KEY RESULTS: Ouabain increased systolic and diastolic cytosolic [Ca²âº](i) , SR [Ca²âº], and SR Ca²âº leak (Ca²âº spark (SparkF) and Ca²âº wave frequency), independently of CaMKII and RyR-Ser(2814) phosphorylation. JTV519 decreased SparkF but also SR Ca²âº load. At matched SR [Ca²âº], Ca²âº leak was significantly reduced by JTV519, but it had no effect on fractional Ca²âº release or Ca²âº wave propagation velocity. In human muscle, JTV519 was negatively inotropic at baseline but significantly enhanced ouabain-induced force and reduced its deleterious effects on diastolic function. CONCLUSIONS AND IMPLICATIONS: JTV519 was effective in reducing SR Ca²âº leak by specifically regulating RyR2 opening at diastolic [Ca²âº](i) in the absence of increased RyR2 phosphorylation at Ser(2814) , extending the potential use of JTV519 to conditions of acute cellular Ca²âº overload.

[Lung pneumatocele in adult patient - case report]. / Plúcna pneumatokéla u dospelého pacienta - kazuistika.

Lung pneumatoceles are characterized by a thin-walled air-filled cavity present in lung parenchyma. Mostly they are the result of acute bronchopneumonia after spontaneous drainage of altered lung parenchyma with subsequent development and progression of cavities due to ventile mechanism. This disease is more prevalent in infants and young children, it is rather rare in adults. In the present case report, videothoracoscopy resection of lung pneumatocele of the right lower lobe was performed a 43-years old man. The operation was indicated for the presence of chronic persisting and progressing pneumatocele as a preventive measure of pneumatocele complications.

Case of Paracoccus yeei infection documented in a transplanted heart.

After a successful cardiac transplantation, routine endomyocardial biopsies showed severe infiltrates comparable with myocarditis. Polymerase chain reaction analysis of native myocardial samples revealed infection with Paracoccus yeei, and the clinical condition of the patient deteriorated. After administration of ciprofloxacin, his clinical condition improved, and further biopsies showed no infiltrates in the cardiac specimens. To our knowledge this is the first documented case of P. yeei infection in a heart transplant patient.

Attitude toward xenotransplantation of patients prior and after human organ transplantation.

Xenotransplantation is a potential strategy to overcome the shortage of human donor organs. As this technique has a major medical and psychological impact on patients and their family and friends, the attitude of patients currently waiting for organ transplantation is important. Therefore, we conducted a survey on the attitude toward xenotransplantation of patients on the waiting list and already transplanted patients. Patients received detailed information before being asked to fill in the questionnaire. We found that 65% would accept xenotransplantation, irrespective of gender, education level or if the patients were on the waiting list or already transplanted. The most common concern was transmission of diseases or genetic material, followed by psychological concerns and ethical issues. More patients had a positive attitude toward accepting cell or tissue transplantation when compared to whole organs. Pig pancreas islet cell transplantation is generally well accepted, patients with diabetes mellitus show even higher acceptance rates than patients without diabetes. In conclusion, xenotransplantation seems to be well accepted in patients who are potential future candidates for organ transplantation. Informing patients about the current status of research tended to decrease acceptance rates slightly.

[Lung hernia following limited thoracotomy]. / Hernia pl'uc po limitovanej torakotómií.

Authors in the adduced work in the form of case report introduce a case of lung herniation as a rare complication after limited thoracotomy. Also on the strength of published literature they briefly discuss about the causes of genesis of lung hernia and the possibilities of their operative solution.

Isoprostanes as markers of oxidative stress-induced cell damage in porcine islet cell isolation.

INTRODUCTION: Mechanical stress and reagents used during the isolation and purification process as well as digestion time and temperature can alter the success of porcine islet cell (PIC) isolation. This study aimed to characterize the occurrence of isoprostanes during PIC isolation using a modified automated Ricordi method and to evaluate their influence on PIC isolation outcome. METHODS: Porcine pancreatic tissue was harvested at the local slaughter house, and 10 PIC isolations were performed using a modified automated Ricordi method. As positive controls for tissue damage-associated oxidative stress, six consecutive PIC isolations were performed in the presence of 1 mug lipopolysaccharide (LPS). PIC were purified by density gradient centrifugation using the Lymphoprep density gradient. Isoprostane measurement was performed using enzyme-linked immunosorbent assay. RESULTS: The final yield of viable and pure PICs in the experimental group was 3479 +/- 542 IEQ/g pancreas, and the LPS group yielded lower cell numbers compared to the experimental group. Isoprostane levels were significantly elevated in the LPS group as compared to the experimental group at all time points during the isolation from the beginning of the digestion process. DISCUSSION: PIC isolation and purification results significantly differed in the two experimental groups, underlining the negative effects of oxidative stress on PIC viability and purity, which impact negatively on PIC transplantation success.

Preoxygenation of different preservation solutions for porcine pancreas preservation.

INTRODUCTION: Organ preservation quality impacts porcine islet cell isolation and transplantation success. Among several preservation methods, the two-layer method is promising, but technically demanding and fails to deliver sufficient oxygen. The use of hyperbaric oxygenation may be an easier, more effective method to supply high partial pressure of oxygen (pO(2)) for organ storage. Therefore, the aim of this study was to test the capability of preoxygenation of various preservation solutions with HBO to maintain high pO(2) levels. METHODS: University of Wisconsin (UW), Custodiol, Perfadex, or Celsior solutions were preoxygenated in a pressure chamber. NaCl served as the control. pO(2) levels were measured at defined times. The oxygen storage capability was evaluated by leaving the storage bottles open for 2 minutes. RESULTS: It was feasible to preoxygenate preservation solutions. The best solution to maintain high pO(2) tensions was Perfadex, followed by Celsior, and UW. DISCUSSION: The greater the amount of oxygen in the preservation solution, the more oxygen can be delivered to the preserved pancreas. Further studies on the influence of preoxygenated preservation solutions on the porcine pancreas are warranted to improve organ quality, porcine islet cell isolation, and transplantation success.

Ductal injection of University of Wisconsin solution prior to pancreas preservation prevents oxidative cell damage.

INTRODUCTION: Several studies have been carried out investigating different preservation methods and preservation solutions for the pancreata of various species. Attention has to be drawn to the extreme vulnerability of porcine pancreata (PP) to oxidative stress due to the lack of endogenous antioxidants. This study sought to evaluate the influence of cannulation and infusion of different volumes of University of Wisconsin (UW) solution immediately after organ retrieval on PP organ quality. METHODS: PP from 24 slaughterhouse pigs were harvested with immediate cannulation of the pancreatic duct for infusion of 10 mL, 20 mL, 50 mL, or 100 mL UW solution. The organs were stored in cold UW solution. Control organs were only stored in UW. After 6 hours of cold ischemia, tissue and supernate samples were analyzed for markers of oxidative cell damage, adenosine triphosphate (ATP) levels, and occurrence of apoptosis. RESULTS: The fewest apoptotic cells were detected in the PP infused with 50 mL UW via the pancreatic duct (PP 50) as compared with all other groups. Oxidative cell damage was lowest and ATP levels were highest in the PP 50 group. DISCUSSION: Because PP 50 showed significantly better results when compared with all other groups, we suggest that infusion of 50 mL UW via the pancreatic duct immediately after organ retrieval may be useful to minimize oxidative cell damage and cell death in PP.

Sensitive serum parameters for hepatocellular carcinoma recurrence monitoring after liver transplantation: a case report.

Liver cell malignancy can be seen as one of the most common indications for hepatic transplantation, but the recurrence potential of the disease significantly limits its beneficial effects. Hepatic factors influencing the recurrence rate, such as nodule size and criteria wherein transplantations are expedited, are still investigated. Pretransplant intraarterial or percutaneous treatment seem to be predictive for recurrence-free patient survival. Early detection of malignancies via serum parameters as a prognostic factor seems promising. This article reports a special case, where despite an elevated, sensitive, serum marker profile, no HCC recurrence was detected over a 2-year follow-up.

Cryopreservation of freshly isolated porcine islet cells.

INTRODUCTION: The use of xenogenic islet cells may be a possibility to overcome the shortage of human donor organs to treat diabetes. Microencapsulation seems to be a promising method for immunoprotection. Since isolation, purification, encapsulation, and transplantation of islet cells are labor intensive, cryopreservation has emerged as an attractive system of islet banking. The aim of this study was to determine the influence of three different freezing media (FM) on viability of freshly isolated porcine islet cells (FIPIC). METHODS: FIPIC were isolated using a modified Ricordi method and purification performed using a Lymphoprep density gradient. Viability of FIPIC prior to freezing and after thawing was determined using the MTT-based Cell Growth Determination Kit. Insulin production was detected using enzyme-linked immunosorbent assay. Three different FM containing dimethylsulfoxide (DMSO) or glycerol and sucrose were used for cryoprotection of FIPIC. RESULTS: Isolation and purification of FIPIC resulted in 95% +/- 1.3% viability and 97% +/- 1.4% purity. Cryopreservation with FM I (containing DMEM, FCS, DMSO) yielded 98.4% and FM III (containing DMEM, FCS, glycerol) 93.1% viability, whereas only 85.6% were alive when cryoprotection is performed with FM II (containing DMSO, BM). Glucose stimulation revealed a loss of 2.8% and 1.9% of insulin secretion per microgram DNA when working with FM I and FM III, but a decrease in glucose-dependent insulin secretion of 7.8% (P < .05) when FIPIC were stored in FM II. DISCUSSION: Low concentrations of DMSO or the use of glycerol and sucrose seem to be equivalent to cryopreserve FIPIC.