Multidrug-resistant bacterial infections after liver transplantation: Prevalence, impact, and risk factors.

BACKGROUND & AIMS: Infections by multidrug-resistant bacteria (MDRB) are an increasing healthcare problem worldwide. This study analyzes the incidence, burden, and risk factors associated with MDRB infections after liver transplant(ation) (LT). METHODS: This retrospective, multicenter cohort study included adult patients who underwent LT between January 2017 and January 2020. Risk factors related to pre-LT disease, surgical procedure, and postoperative stay were analyzed. Multivariate logistic regression analysis was performed to identify independent predictors of MDRB infections within the first 90 days after LT. RESULTS: We included 1,045 LT procedures (960 patients) performed at nine centers across Spain. The mean age of our cohort was 56.8 ± 9.3 years; 75.4% (n = 782) were male. Alcohol-related liver disease was the most prevalent underlying etiology (43.2.%, n = 451). Bacterial infections occurred in 432 patients (41.3%) who presented with a total of 679 episodes of infection (respiratory infections, 19.3%; urinary tract infections, 18.5%; bacteremia, 13.2% and cholangitis 11%, among others). MDRB were isolated in 227 LT cases (21.7%) (348 episodes). Enterococcus faecium (22.1%), Escherichia coli (18.4%), and Pseudomonas aeruginosa (15.2%) were the most frequently isolated microorganisms. In multivariate analysis, previous intensive care unit admission (0-3 months before LT), previous MDRB infections (0-3 months before LT), and an increasing number of packed red blood cell units transfused during surgery were identified as independent predictors of MDRB infections. Mortality at 30, 90, 180, and 365 days was significantly higher in patients with MDRB isolates. CONCLUSION: MDRB infections are highly prevalent after LT and have a significant impact on prognosis. Enterococcus faecium is the most frequently isolated multi-resistant microorganism. New pharmacological and surveillance strategies aimed at preventing MDRB infections after LT should be considered for patients with risk factors. IMPACT AND IMPLICATIONS: Multidrug-resistant bacterial infections have a deep impact on morbidity and mortality after liver transplantation. Strategies aimed at improving prophylaxis, early identification, and empirical treatment are paramount. Our study unveiled the prevalence and main risk factors associated with these infections, and demonstrated that gram-positive bacteria, particularly Enterococcus faecium, are frequent in this clinical scenario. These findings provide valuable insights for the development of prophylactic and empirical antibiotic treatment protocols after liver transplantation.

Fatty Liver Disease, Metabolism and Alcohol Interplay: A Comprehensive Review.

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide, and its incidence has been increasing in recent years because of the high prevalence of obesity and metabolic syndrome in the Western population. Alcohol-related liver disease (ArLD) is the most common cause of cirrhosis and constitutes the leading cause of cirrhosis-related deaths worldwide. Both NAFLD and ArLD constitute well-known causes of liver damage, with some similarities in their pathophysiology. For this reason, they can lead to the progression of liver disease, being responsible for a high proportion of liver-related events and liver-related deaths. Whether ArLD impacts the prognosis and progression of liver damage in patients with NAFLD is still a matter of debate. Nowadays, the synergistic deleterious effect of obesity and diabetes is clearly established in patients with ArLD and heavy alcohol consumption. However, it is still unknown whether low to moderate amounts of alcohol are good or bad for liver health. The measurement and identification of the possible synergistic deleterious effect of alcohol consumption in the assessment of patients with NAFLD is crucial for clinicians, since early intervention, advising abstinence and controlling cardiovascular risk factors would improve the prognosis of patients with both comorbidities. This article seeks to perform a comprehensive review of the pathophysiology of both disorders and measure the impact of alcohol consumption in patients with NAFLD.

Faecal Microbiota Transplantation, Paving the Way to Treat Non-Alcoholic Fatty Liver Disease.

Non-alcoholic fatty liver disease (NAFLD) is currently the most prevalent cause of chronic liver disease (CLD). Currently, the only therapeutic recommendation available is a lifestyle change. However, adherence to this approach is often difficult to guarantee. Alteration of the microbiota and an increase in intestinal permeability seem to be key in the development and progression of NAFLD. Therefore, the manipulation of microbiota seems to provide a promising therapeutic strategy. One way to do so is through faecal microbiota transplantation (FMT). Here, we summarize the key aspects of FMT, detail its current indications and highlight the most recent advances in NAFLD.

High accuracy of spleen stiffness measurement in diagnosing clinically significant portal hypertension in metabolic-associated fatty liver disease.

BACKGROUND AND AIMS: Spleen stiffness measurement (SSM) by vibration-controlled transient elastography (VCTE) has been tested in a limited number of studies versus hepatic venous pressure gradient (HVPG), especially with the 100 Hz spleen-specific module. The current study aims to evaluate the diagnostic performance of this novel module for detecting clinically significant portal hypertension (CSPH) in a cohort of compensated patients with metabolic-associated fatty liver disease (MAFLD) as the main aetiology and to improve the performance of the Baveno VII criteria for CSPH diagnosis by including SSM. METHODS: This is a retrospective single-centre study including patients with available measurements of HVPG, Liver stiffness measurement (LSM) and SSM by VCTE with the 100 Hz module. Area under the receiver operating characteristic (AUROC) curve analysis was conducted to identify dual cut-offs (rule-out and rule-in) associated with the absence/presence of CSPH. The diagnostic algorithms were adequate if negative predictive value (NPV) and positive predictive values (PPV) were >90%. RESULTS: A total of 85 patients were included, 60 MAFLD and 25 non-MAFLD. SSM showed a good correlation with HVPG (MAFLD: r = .74; p < .0001; non-MAFLD: r = .62; p < .0011). In MAFLD patients, SSM had a high accuracy in discarding/diagnosing CSPH (cut-off values of <40.9 and >49.9 kPa, AUC 0.95). The addition of these cut-offs in a sequential or combined approach to the Baveno VII criteria significantly reduced the grey zone (60% vs. 15%-20%), while maintaining adequate NPV and PPV. CONCLUSIONS: Our findings support the utility of SSM for diagnosing CSPH in MAFLD patients and demonstrate that the addition of SSM to the Baveno VII criteria increases accuracy.

Portal Vein Thrombosis in the Setting of Cirrhosis: A Comprehensive Review.

Portal vein thrombosis constitutes the most common thrombotic event in patients with cirrhosis, with increased rates in the setting of advanced liver disease. Despite being a well-known complication of cirrhosis, the contribution of portal vein thrombosis to hepatic decompensation and overall mortality is still a matter of debate. The incorporation of direct oral anticoagulants and new radiological techniques for portal vein recanalization have expanded our therapeutic arsenal. However, the lack of large prospective observational studies and randomized trials explain the heterogenous diagnostic and therapeutic recommendations of current guidelines. This article seeks to make a comprehensive review of the pathophysiology, clinical features, diagnosis, and treatment of portal vein thrombosis in patients with cirrhosis.

Analysis of the movements generated by a multi-field functional electrical stimulation device for upper extremity rehabilitation.

BACKGROUND: The most common chronic sequela after stroke is the loss of arm function, and functional electrical stimulation (FES) applied to the forearm muscles is one of the options to treat it. Surface multi-field electrodes have emerged, showing a great potential to improve the selectivity of the stimulation, delay muscle fatigue, and provide easier donning and doffing. The muscular selectivity takes on special relevance in the rehabilitation of the upper extremity as hand dexterity requires a wide diversity of specific muscle actions. METHODS: This pilot study analyses the movements generated in the wrist and fingers using a commercial multi-field technology-based FES device (Fesia Grasp). The study included five patients with hemiplegic subacute stroke, in which scanning of all cathodes of the electrode was carried out daily for 5 days, in two different forearm positions, with the resulting movements being labeled by experienced therapists. RESULTS: The aim of this pilot study was to determine if there were differences between subjects and between forearm positions in terms of produced movements. Movements of the wrist (two movements) and the fingers (six movements) could be achieved in two different forearm positions. CONCLUSIONS: The multi-field electrode of Fesia Grasp enables to generate a wide range of movements of the hand in different positions. This fact could allow to produce more physiological movement patterns during the rehabilitation process with FES, which could have a beneficial effect on the recovery of patients with neurological diseases.

SARS-CoV-2 and Liver Transplant: How Has It Behaved in This Sixth Wave?

BACKGROUND: Since the declaration of a new variant of concern (VOC), Omicron, by the World Health Organization in November 2021, a quick spread has been documented worldwide, being the main VOC in the sixth wave in Spain. The Omicron variant has more transmissibility, lower virulence, and less risk of severe disease than previously described VOC. Here we analyze the current wave of severe acute respiratory syndrome coronavirus 2 infection in liver transplant recipients (LTRs). METHODS: A retrospective observational study of 355 LTRs was conducted in La Rioja and Cantabria regions of Spain. Epidemiological and clinical parameters were gathered on the basis of clinical records and telephone interviews. RESULTS: In the current wave of infection, a higher number of LTRs have been found to be infected than the sum of the previous 5 waves (30 versus 16 LTRs). Of the 30 infected LTRs, 29 (96.6%) had received 3 vaccine doses (mRNA based), in a median of 93 d (interquartile range, 86-108) before infection. Eight of 30 LTRs (24.0%) were asymptomatic and 21 LTRs (67.8%) were with mild symptoms with a mean duration of 4.6 d (interquartile range, 2.5-7), whereas in the unvaccinated LTRs, the symptoms were fever, nausea, vomiting, and diarrhea. Moreover, in the sixth wave, intrafamiliar transmission was the main route of infection (17/30; 56.6%), and nosocomial transmission was confirmed in 2 LTRs (6.6%). CONCLUSIONS: In our series, increased transmissibility of the Omicron variant was confirmed, including nosocomial infection, with a lower risk of severe disease in LTRs. These findings could be supported by the universal vaccination of LTRs and less virulence of the Omicron variant.

Impact of the COVID-19 lockdown on liver transplant recipients. A single center observational study.

BACKGROUND: the impact of the COVID-19 outbreak and lockdown on liver transplant (LT) patients remains unknown. The aim of this cross-sectional study was to assess the consequences of the COVID-19 pandemic on the physical and mental health of LT patients during the lockdown period. METHODS: a web-based questionnaire was emailed to 238 LT patients undergoing regular follow-up at our unit between August and October 2020. This pseudonymized survey explored demographic and lifestyle variables (i.e., eating and physical habits), disruptions in routine medical care, different dimensions of mental health, COVID-19-related mood and coping (worries/anxiety, depression, insomnia, fear of COVID, resilience, etc.) and health perception using different validated instruments. RESULTS: altogether, 48.7 % (116 of 238) LT recipients accepted to participate in the study, 104 of whom gave their consent to publish the data. The median age was 63 years. Up to 39.4 % presented worrying scores indicating moderate/severe generalized anxiety disorder (GAD), whereas 25.5 % exhibited moderate/severe insomnia and only 10.5 % moderate/severe depression. Forty patients (38.5 %) gained weight, 24 % experienced a worsening in their eating habits and 63.4 % referred to practicing less or much less exercise during the lockdown. Only 25 % perceived a worsening in the control of their chronic comorbidities. Missed medical appointments (0.9 %) or poor adherence to therapy (1.9 %) were exceptional. CONCLUSIONS: COVID-19 lockdown has negatively impacted the mental and physical health of LT patients. Long-term consequences remain unclear.

Hand dexterity rehabilitation using selective functional electrical stimulation in a person with stroke.

We report a 69 year old who suffered a cardioembolic ischaemic stroke on 23 September 2019, which resulted in a left hemiplegia with motor impairment in upper and lower extremities that made impossible for her to use the affected arm in daily living activities. The person commenced her comprehensive physiotherapy programme based on functional electrical stimulation (FES) in Fesia Clinic rehabilitation centre in October 2020. A multifield technology-based FES device was used, which allowed to train different selective movements in isolation and combined with mirror therapy, achieving excellent functional outcomes.