Diagnosing Viral Infections Through T-Cell Receptor Sequencing of Activated CD8+ T Cells.

T-cell-based diagnostic tools identify pathogen exposure but lack differentiation between recent and historical exposures in acute infectious diseases. Here, T-cell receptor (TCR) RNA sequencing was performed on HLA-DR+/CD38+CD8+ T-cell subsets of hospitalized coronavirus disease 2019 (COVID-19) patients (n = 30) and healthy controls (n = 30; 10 of whom had previously been exposed to severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]). CDR3α and CDR3ß TCR regions were clustered separately before epitope specificity annotation using a database of SARS-CoV-2-associated CDR3α and CDR3ß sequences corresponding to >1000 SARS-CoV-2 epitopes. The depth of the SARS-CoV-2-associated CDR3α/ß sequences differentiated COVID-19 patients from the healthy controls with a receiver operating characteristic area under the curve of 0.84 ± 0.10. Hence, annotating TCR sequences of activated CD8+ T cells can be used to diagnose an acute viral infection and discriminate it from historical exposure. In essence, this work presents a new paradigm for applying the T-cell repertoire to accomplish TCR-based diagnostics.

COVID-19 in three waves in a tertiary referral hospital in Belgium: a comparison of patient characteristics, management, and outcome.

PURPOSE: Few studies have compared patient characteristics, clinical management, and outcome of patients with COVID-19 between the different epidemic waves. In this study, we describe patient characteristics, treatment, and outcome of patients admitted for COVID-19 in the Antwerp University Hospital over the first three epidemic waves of 2020-2021. METHODS: Retrospective observational study of COVID-19 patients in a Belgian tertiary referral hospital. All adult patients with COVID-19, hospitalized between February 29, 2020, and June 30, 2021, were included. Standardized routine medical data was collected from patient records. Risk factors were assessed with multivariable logistic regression. RESULTS: We included 722 patients, during the first (n = 179), second (n = 347) and third (n = 194) wave. We observed the lowest disease severity at admission during the first wave, and more elderly and comorbid patients during the second wave. Throughout the subsequent waves we observed an increasing use of corticosteroids and high-flow oxygen therapy. In spite of increasing number of complications throughout the subsequent waves, mortality decreased each wave (16.6%,15.6% 11.9% in 1st, 2nd and 3rd wave respectively). C-reactive protein above 150 mg/L was predictive for the need for intensive care unit admission (odds ratio (OR) 3.77, 95% confidence interval (CI) 2.32-6.15). A Charlson comorbidity index ≥ 5 (OR 5.68, 95% CI 2.54-12.70) and interhospital transfers (OR 3.78, 95% CI 2.05-6.98) were associated with a higher mortality. CONCLUSIONS: We observed a reduction in mortality each wave, despite increasing comorbidity. Evolutions in patient management such as high-flow oxygen therapy on regular wards and corticosteroid use may explain this favorable evolution.

Human Filariasis in Travelers and Migrants: A Retrospective 25-year Analysis at the Institute of Tropical Medicine, Antwerp, Belgium.

BACKGROUND: Information on human filariasis in international travelers is scarce. We describe the epidemiology, clinical presentation, and outcome of these infections in a reference travel clinic over the past decades. METHODS: We reviewed all cases of filariasis diagnosed at the Institute of Tropical Medicine, Antwerp, Belgium, from 1994 to 2018. Diagnosis was obtained by either parasitological methods (confirmed) or strict clinical case definitions (probable). We assessed the characteristics of cases at diagnosis and response to therapy within 3-12 months. RESULTS: A total of 320 patients (median age: 41 years; 71% males) were diagnosed with 327 filarial infections (Wuchereria bancrofti = 6, Onchocerca volvulus = 33, Loa loa = 150, Mansonella perstans = 130, unspecified species = 8). Diagnosis was confirmed in 213/320 (67%) patients. European long-term travelers accounted for 166 patients (52%) and visitors/migrants from tropical countries for another 110 (34%). Central Africa was the likely region of acquisition for 294 (92%) patients. The number of filariasis cases decreased from 21.5/year on average in the 1990s to 6.3/year in the past decade, when loiasis became predominant. Cases reported symptoms in >80% of all filarial infections but mansonellosis (45/123 single infections; 37%). Lymphatic filariasis and onchocerciasis cases responded well to conventional therapy. However, 30% of patients with loiasis and mansonellosis experienced treatment failure (with diethylcarbamazine and levamisole-mebendazole, respectively). CONCLUSIONS: The burden and species distribution of filariasis in travelers evolved in the past decades. Most presentations were symptomatic. Case management would benefit from more effective therapies for loiasis and mansonellosis.

Efficacy and Tolerability of Quinacrine Monotherapy and Albendazole Plus Chloroquine Combination Therapy in Nitroimidazole-Refractory Giardiasis: A TropNet Study.

BACKGROUND: Giardiasis failing nitroimidazole first-line treatment is an emerging problem in returning European travelers. We present data on the efficacy and tolerability of 2 second-line treatment regimens. METHODS: This prospective, open-label, multicenter study assessed the efficacy and tolerability of quinacrine monotherapy (100 mg 3 times per day for 5 days) and albendazole plus chloroquine combination therapy (400 mg twice daily plus 155 mg twice daily for 5 days) in nitroimidazole-refractory giardiasis. The defined end points were the clinical outcome, assessed at week 5 after treatment and the parasitological outcome, assessed using microscopy of 2 stool samples, ≥2 to ≤5 weeks after treatment. RESULTS: A total of 106 patients were included in the study. Quinacrine achieved clinical and parasitological cure in 81% (59/73) and 100% (56/56), respectively. Albendazole plus chloroquine achieved clinical and parasitological cure in 36% (12/33) and 48% (12/25), respectively. All patients (9/9) who clinically and parasitologically failed albendazole plus chloroquine treatment and opted for retreatment with quinacrine achieved clinical cure. Mild to moderate treatment-related adverse events were reported by 45% and 30% of patients treated with quinacrine and albendazole plus chloroquine, respectively. One patient treated with quinacrine developed severe neuropsychiatric side effects. The majority of nitroimidazole-refractory Giardia infections (57%) were acquired in India. CONCLUSIONS: Quinacrine was a highly effective treatment in nitroimidazole-refractory giardiasis, but patients should be cautioned on the low risk of severe neuropsychiatric adverse event. Albendazole plus chloroquine had a low cure rate in nitroimidazole-refractory giardiasis. Nitroimidazole-refractory giardiasis was primarily seen in travelers returning from India.

Acute-phase diagnosis of murine and scrub typhus in Belgian travelers by polymerase chain reaction: a case report.

BACKGROUND: Rickettsiosis is a potential life threatening infectious disease in travelers. Clinical recognition is not always straightforward, as typical manifestations such as rash and/or eschar may be absent. Definite diagnosis is based on seroconversion and therefore often delayed until the convalescent phase of disease. CASE PRESENTATION: In this case report, we describe four patients with severe travel-related rickettsiosis (two patients with murine- and two patients with scrub typhus), in whom acute- phase diagnosis was possible by real-time polymerase chain reaction on serum or blood. CONCLUSIONS: Despite its limitations, we think that polymerase chain reaction can contribute significantly to the early diagnosis and treatment of rickettsial disease in travelers.

Outbreak of trichinellosis related to eating imported wild boar meat, Belgium, 2014.

Trichinellosis is a rare parasitic zoonosis caused by Trichinella following ingestion of raw or undercooked meat containing Trichinella larvae. In the past five years, there has been a sharp decrease in human trichinellosis incidence rates in the European Union due to better practices in rearing domestic animals and control measures in slaughterhouses. In November 2014, a large outbreak of trichinellosis occurred in Belgium, related to the consumption of imported wild boar meat. After a swift local public health response, 16 cases were identified and diagnosed with trichinellosis. Of the 16 cases, six were female. The diagnosis was confirmed by serology or the presence of larvae in the patients' muscle biopsies by histology and/or PCR. The ensuing investigation traced the wild boar meat back to Spain. Several batches of imported wild boar meat were recalled but tested negative. The public health investigation allowed us to identify clustered undiagnosed cases. Early warning alerts and a coordinated response remain indispensable at a European level.

Patient characteristics and antimicrobial susceptibility profiles of Escherichia coli and Klebsiella pneumoniae infections in international travellers: a GeoSentinel analysis.

BACKGROUND: Antimicrobial resistance (AMR) is a global health crisis, with Enterobacterales including Escherichia coli and Klebsiella pneumoniae playing significant roles. While international travel to low- and middle-income countries is linked to colonisation with AMR Enterobacterales, the clinical implications, particularly the risk of subsequent infection, remain unclear due to limited data. We aimed to characterise E. coli and K. pneumoniae infections in travellers and the antimicrobial susceptibility profiles of their isolates. METHODS: We analysed data on E. coli and K. pneumoniae infections in travellers collected at GeoSentinel sites between 2015 and 2022, focusing on epidemiological, clinical and microbiological characteristics. We defined multi-drug resistance (MDR) as non-susceptibility to agents from at least three drug classes. RESULTS: Over the 8-year period, we included 655 patients (median age 41 years; 74% female) from 57 sites in 27 countries, with 584 E. coli and 72 K. pneumoniae infections. Common travel regions included Sub-Saharan Africa, Southeast Asia, and South-Central Asia. Urinary tract infections predominated. Almost half (45%) were hospitalised. Among infections with antimicrobial susceptibility data across three or more drug classes, 203/544 (37%) E. coli and 19/67 (28%) K. pneumoniae demonstrated MDR. Over one-third of E. coli and K. pneumoniae isolates were non-susceptible to third-generation cephalosporins and cotrimoxazole, with 38% and 28% non-susceptible to fluoroquinolones, respectively. Travellers to South-Central Asia most frequently had isolates non-susceptible to third-generation cephalosporins, fluoroquinolones and carbapenems. We observed increasing frequencies of phenotypic extended spectrum beta-lactamase and carbapenem resistance over time. CONCLUSIONS: E. coli and K. pneumoniae infections in travellers, particularly those to Asia, may be challenging to empirically treat. Our analysis highlights the significant health risks these infections pose to travellers and emphasises the escalating global threat of AMR. Enhanced, systematic AMR surveillance in travellers is needed, along with prospective data on infection risk post travel-related AMR organism acquisition.

Rabies post-exposure prophylaxis: A retrospective analysis of timing of initiation and antibody responses in a Belgian cohort.

BACKGROUND: We aimed to determine the timeliness of rabies post-exposure prophylaxis (PEP) and the proportion of individuals with an adequate antibody response post-PEP among those attending the Belgian national reference center. METHODS: Retrospective analysis of patient records who attended our center from 2018 to 2023. Delay was defined as rabies immunoglobulin (RIG) and vaccine initiation beyond 2 calendar days after exposure. Antibodies were measured by rapid fluorescent focus inhibition test (RFFIT) after PEP in high-risk exposures. A titer ≥0.5 IU/ml was considered adequate. RESULTS: We reviewed 317 patient records. Among individuals with inland exposure (n = 103), 85 % timely received PEP. Among travelers exposed abroad (n = 214), administration of RIG and vaccine initiation were timely in 30 % and 50 % of cases, respectively. An adequate antibody response was detected in 99.5 % (195/196) individuals. CONCLUSION: Substantial PEP delays among travelers were observed. The robust antibody responses suggest that routine serological follow-up is not necessary for all patients.

Leveraging T-cell receptor - epitope recognition models to disentangle unique and cross-reactive T-cell response to SARS-CoV-2 during COVID-19 progression/resolution.

Despite the general agreement on the significance of T cells during SARS-CoV-2 infection, the clinical impact of specific and cross-reactive T-cell responses remains uncertain. Understanding this aspect could provide insights for adjusting vaccines and maintaining robust long-term protection against continuously emerging variants. To characterize CD8+ T-cell response to SARS-CoV-2 epitopes unique to the virus (SC2-unique) or shared with other coronaviruses (CoV-common), we trained a large number of T-cell receptor (TCR) - epitope recognition models for MHC-I-presented SARS-CoV-2 epitopes from publicly available data. These models were then applied to longitudinal CD8+ TCR repertoires from critical and non-critical COVID-19 patients. In spite of comparable initial CoV-common TCR repertoire depth and CD8+ T-cell depletion, the temporal dynamics of SC2-unique TCRs differed depending on the disease severity. Specifically, while non-critical patients demonstrated a large and diverse SC2-unique TCR repertoire by the second week of the disease, critical patients did not. Furthermore, only non-critical patients exhibited redundancy in the CD8+ T-cell response to both groups of epitopes, SC2-unique and CoV-common. These findings indicate a valuable contribution of the SC2-unique CD8+ TCR repertoires. Therefore, a combination of specific and cross-reactive CD8+ T-cell responses may offer a stronger clinical advantage. Besides tracking the specific and cross-reactive SARS-CoV-2 CD8+ T cells in any TCR repertoire, our analytical framework can be expanded to more epitopes and assist in the assessment and monitoring of CD8+ T-cell response to other infections.

Proline-specific peptidase activities (DPP4, PRCP, FAP and PREP) in plasma of hospitalized COVID-19 patients.

BACKGROUND: COVID-19 patients experience several features of dysregulated immune system observed in sepsis. We previously showed a dysregulation of several proline-selective peptidases such as dipeptidyl peptidase 4 (DPP4), fibroblast activation protein alpha (FAP), prolyl oligopeptidase (PREP) and prolylcarboxypeptidase (PRCP) in sepsis. In this study, we investigated whether these peptidases are similarly dysregulated in hospitalized COVID-19 patients. METHODS: Fifty-six hospitalized COVID-19 patients and 32 healthy controls were included. Enzymatic activities of DPP4, FAP, PREP and PRCP were measured in samples collected shortly after hospital admission and in longitudinal follow-up samples. RESULTS: Compared to healthy controls, both DPP4 and FAP activities were significantly lower in COVID-19 patients at hospital admission and FAP activity further decreased significantly in the first week of hospitalization. While PRCP activity remained unchanged, PREP activity was significantly increased in COVID-19 patients at hospitalization and further increased during hospital stay and stayed elevated until the day of discharge. CONCLUSION: The changes in activities of proline-selective peptidases in plasma are very similar in COVID-19 and septic shock patients. The pronounced decrease in FAP activity deserves further investigation, both from a pathophysiological viewpoint and as its utility as a part of a biomarker panel.

Activation of the Carboxypeptidase U (CPU, TAFIa, CPB2) System in Patients with SARS-CoV-2 Infection Could Contribute to COVID-19 Hypofibrinolytic State and Disease Severity Prognosis.

Coronavirus disease 2019 (COVID-19) is a viral lower respiratory tract infection caused by the highly transmissible and pathogenic SARS-CoV-2 (severe acute respiratory-syndrome coronavirus-2). Besides respiratory failure, systemic thromboembolic complications are frequent in COVID-19 patients and suggested to be the result of a dysregulation of the hemostatic balance. Although several markers of coagulation and fibrinolysis have been studied extensively, little is known about the effect of SARS-CoV-2 infection on the potent antifibrinolytic enzyme carboxypeptidase U (CPU). Blood was collected longitudinally from 56 hospitalized COVID-19 patients and 32 healthy controls. Procarboxypeptidase U (proCPU) levels and total active and inactivated CPU (CPU+CPUi) antigen levels were measured. At study inclusion (shortly after hospital admission), proCPU levels were significantly lower and CPU+CPUi antigen levels significantly higher in COVID-19 patients compared to controls. Both proCPU and CPU+CPUi antigen levels showed a subsequent progressive increase in these patients. Hereafter, proCPU levels decreased and patients were, at discharge, comparable to the controls. CPU+CPUi antigen levels at discharge were still higher compared to controls. Baseline CPU+CPUi antigen levels (shortly after hospital admission) correlated with disease severity and the duration of hospitalization. In conclusion, CPU generation with concomitant proCPU consumption during early SARS-CoV-2 infection will (at least partly) contribute to the hypofibrinolytic state observed in COVID-19 patients, thus enlarging their risk for thrombosis. Moreover, given the association between CPU+CPUi antigen levels and both disease severity and duration of hospitalization, this parameter may be a potential biomarker with prognostic value in SARS-CoV-2 infection.

Time of administration of rabies immunoglobulins and adequacy of antibody response upon post-exposure prophylaxis: a descriptive retrospective study in Belgium.

Background: Data on rabies post-exposure prophylaxis (PEP) and the use of human rabies immunoglobulins (HRIG) in Belgium are scarce. The main objective of this study was to evaluate the timely administration of HRIG after rabies exposure. The secondary objective was to evaluate the adequate antibody response following PEP.Methods: We reviewed all medical records from July 2017 to June 2018 of patients seeking care at, or referred to, the Institute of Tropical Medicine and the University Hospital, Antwerp for the administration of human rabies immunoglobulins following potential rabies exposure abroad or in Belgium.A timely response was defined as starting HRIG with a delay of ≤48 h and rabies vaccination in the first 7 days after exposure.Adequate antibody response was defined as a titer of >5.0 IU/mL in case of bat-related exposure and >3.0 IU/mL in case of exposure to other animals. Titers were measured 10 days after the last PEP vaccine dose, using the rapid fluorescent focus inhibition test (RFFIT).Results: Of the 92 cases treated with HRIG, 75 were evaluated.The majority of injuries were acquired in Asia (n = 26,34%) and in Western Europe (n = 18, 24%), of which 17 in Belgium. The five most frequently recorded countries overseas were Indonesia (n = 13), Thailand (n = 7), Morocco (n = 4), Peru (n = 3) and Costa Rica (n = 3). Administration of immunoglobulins was related to injuries by dogs (36%), monkeys (25%) or bats (22%).A timely response was observed in 16 (21,33%) and in 55 (73,33%) of subjects receiving HRIG (≤48 h) or rabies vaccine (<7days) respectively. The mean time between exposure and the first administered dose of rabies vaccine and HRIG was 7.7 and 8.7 days, respectively. The mean delay for HRIG administration was 9.6 days and 6 days for abroad and inland risks, respectively.In 15 of 16 (94%) bat-related cases the antibody titer after full PEP was >5.0 IU/ml. In 38 of 47 (81%) cases related to other animals the RFFIT titer was >3.0 IU/ml. All low-responders received additional rabies injections.Conclusion: This study showed a substantial time delay between the animal-related risk and the administration of HRIG, in particular when the injury occurred abroad. More targeted communication about the risks of rabies and preventable measures may reduce this delay.Furthermore, the antibody response was inadequate in some cases following full PEP administration according to the Belgian recommendation.

Should We Screen HIV-Positive Migrants for Strongyloidiasis?

BACKGROUND: Strongyloides stercoralis, a nematode endemic in all (sub)tropical regions, can cause life-threatening disease, especially in immunosuppressed patients. Many countries with high HIV-prevalence rates are also highly S. stercoralis endemic, and co-infection may occur. METHODS: Retrospective study based on serological testing for S. stercoralis in all HIV-infected migrants followed at the Institute of Tropical Medicine, Antwerp, Belgium. If untested, serologic testing was performed on stored samples, dating from the first HIV viral load determination. The epidemiological, clinical and laboratory features of patients with and without strongyloidiasis were retrieved from the electronic medical files. RESULTS: Of the 2846 HIV patients in active follow-up, 723 (25.4%) had a migration background. Thirty-six patients (5.1%) were diagnosed with Strongyloides co-infection, including 29 during their medical evaluation and seven retrospectively. Patients had a median age of 35.3 years (IQR 30.3-44.4), 28 patients (78%) originated from Sub-Saharan Africa and median time in Belgium was 3.5 years (IQR 0.8-5.7). Symptoms compatible with strongyloidiasis were present in 17 (47%) patients, of whom two were diagnosed retrospectively. Eosinophilia (eosinophil cell count > 450/µL) was observed in 19 (53%) participants. Median CD4 level was 386 /µL (IQR 299-518) at diagnosis of co-infection. Of note, 8 (22%) patients with strongyloidiasis had no reported symptoms nor eosinophilia. None of the patients developed hyperinfection syndrome. There were no differences in age, gender, geographic origin, clinical presentation, CD4 level or viral load between patients with and without strongyloidiasis. Only eosinophilia was strongly correlated with the presence of Strongyloides in multivariate analysis (OR 10.74 (95% CI 5.19-22.25), p < 0.001); the positive likelihood ratio (LR+) of eosinophilia for strongyloidiasis was 5.38 (95% CI 3.66-7.91). CONCLUSION: Strongyloidiasis was diagnosed in 5.1% of HIV-infected migrants. Eosinophilia had good confirming power for the presence of the disease. However, a sizeable proportion (22%) of co-infected individuals were asymptomatic and had normal eosinophil count, supporting universal screening of all HIV-positive patients native to tropical countries.

Motivation and Weight Loss Expectations in Bariatric Surgery Candidates: Association with 1- and 2-Year Results After Bariatric Surgery.

PURPOSE: There are discrepancies between patients' expected weight loss and what is considered achievable after bariatric surgery. This study describes the association between patients' expectations and actual weight loss, 1 and 2 years postoperatively. MATERIALS AND METHODS: A prospective observational study was performed. The association between expectations and actual weight loss (% total weight loss) was explored using linear regression analyses, adjusting for baseline demographics, surgery types, and self-esteem (Rosenberg self-esteem scale) and repeated separately per gender. Gender differences in motivations were explored using Chi-square tests. RESULTS: Of 440 patients at baseline, results on 368 (84%) at 1 year and 341 (78%) patients at 2 years were available. Significant and opposite associations were found when analyzing genders separately. There was a significant negative association between expectations and %TWL in men at 1 year (ß - 0.23, p = 0.04) and 2 years postoperatively (ß - 0.26, p = 0.03), indicating smaller weight loss for greater expectations. In women, a significant positive association (ß 0.24, p < 0.01) was found 2 years postoperatively, indicating greater weight loss for greater expectations. Both genders were mainly motivated by health concerns, but women were also motivated by reduced self-confidence to lose weight. CONCLUSIONS: Higher expectations were negatively associated with weight loss in men, but positively in women. This may be due to men being motivated by physical complaints, which improve with lower weight-loss. Women are also driven by reduced self-confidence, which may influence weight loss maintenance behaviors. Higher weight loss goals should not be considered as a contra-indication for surgery, but may be utilized to achieve patients' goals.

Clinical Utility of the Nonstructural 1 Antigen Rapid Diagnostic Test in the Management of Dengue in Returning Travelers With Fever.

BACKGROUND: Rapid diagnostic test (RDT) detecting the nonstructural 1 (NS1) antigen is increasingly used for dengue diagnosis in endemic and nonendemic settings, but its clinical utility has not been studied in travel clinic practice. METHODS: From August 2012 to July 2016, travelers returning from the tropics with fever were evaluated in the Institute of Tropical Medicine (Antwerp, Belgium) with the routine use of NS1 antigen RDT that provided results within 1 hour. We determined the diagnostic performance, assessed the management of patients with a positive RDT result, and compared it with that of historical cases of dengue diagnosed from 2000 to 2006, when only antibody detection assays were available. RESULTS: Of 335 travelers evaluated for fever, 54 (16%) were diagnosed with dengue, including 1 severe case. Nonstructural 1 antigen RDT was performed in 308 patients. It was truly positive in 43 of 52 tested dengue cases and falsely positive in only 1 of the 256 nondengue cases; therefore, sensitivity was 82.7% (95% confidence interval [CI], 74.4%-93.0%) and specificity was 99.6% (95% CI, 98.8%-100%). Only 3 (7%) of the 43 febrile travelers "immediately" diagnosed by RDT were admitted, and only 2 (5%) were given empirical antibacterial treatment, without adverse outcome. Admission and antibiotic prescription rates were significantly higher in the historical cases (n = 43) diagnosed by antibody detection (33%, P = .006 and 26%, P = .014, respectively), although the frequency of severe dengue was similar. CONCLUSIONS: In our practice, the diagnostic performance of NS1 antigen RDT substantially contributed in withholding unnecessary hospitalization and antibiotherapy in dengue patients.

Redo Laparoscopic Gastric Bypass: One-Step or Two-Step Procedure?

BACKGROUND: The adjustable gastric band (AGB) is a bariatric procedure that used to be widely performed. However, AGB failure-signifying band-related complications or unsatisfactory weight loss, resulting in revision surgery (redo operations)-frequently occurs. Often this entails a conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). This can be performed as a one-step or two-step (separate band removal) procedure. METHODS: Data were collected from patients operated from 2012 to 2014 in a single bariatric centre. We compared 107 redo LRYGB after AGB failure with 1020 primary LRYGB. An analysis was performed of the one-step vs. two-step redo procedures. All redo procedures were performed by experienced bariatric surgeons. RESULTS: No difference in major complication rate was seen (2.8 vs. 2.3 %, p = 0.73) between redo and primary LRYGB, and overall complication severity for redos was low (mainly Clavien-Dindo 1 or 2). Weight loss results were comparable for primary and redo procedures. The one-step and two-step redos were comparable regarding complication rates and readmissions. The operating time for the one-step redo LRYGB was 136 vs. 107.5 min for the two-step (median, p < 0.001), excluding the operating time of separate AGB removal (mean 61 min, range 36-110). CONCLUSIONS: Removal of a failed AGB and LRYGB in a one-step procedure is safe when performed by experienced bariatric surgeons. However, when erosion or perforation of the AGB occurs, we advise caution and would perform the redo LRYGB as a two-step procedure. Equal weights can be achieved at 1 year post redo LRYGB as after primary LRYGB procedures.

Early Postoperative Progression to Solid Foods Is Safe After Roux-en-Y Gastric Bypass.

BACKGROUND: Even though admission time is reduced with the implementation of various enhanced recovery protocols, many clinics still instruct patients after weight loss surgery to maintain a fluid or minced-food diet for at least 2 weeks postoperatively. We reasoned that with adequate preoperative instructions, including adequate chewing of all foods, early progression to solid foods would not increase the risk of (gastro)enterostomy leakage. METHODS: In December 2010, a new dietary protocol was implemented for all patients undergoing a Roux-en-Y gastric bypass, allowing progression to solid foods from 12 h postprocedure onwards. All patients received thorough preoperative eating instructions and eating awareness counselling from a qualified dietician and psychologist. A retrospective study was performed of 936 patients who underwent a primary or redo laparoscopic Roux-en-Y gastric bypass between January 2011 and June 2014 in our hospital. All 30-day complications, readmissions and reoperations were noted. RESULTS: No 30-day loss to follow-up occurred. Overall 30-day complication rate was 9.4%, with gastrointestinal leakage occurring in only 0.6%. A low threshold for readmission was maintained due to the short mean admission time of 1.87 days. Readmission rate was 4.8%--mainly for observation of postoperative pain--and 1.8% of our patients required reoperation within 30 days. Mortality was 0.1%. Our results are comparable to results published by other Dutch centres advocating conventional diets, showing no increase in leakage or other complications. CONCLUSIONS: We conclude that early progression to solid foods after Roux-en-Y gastric bypass surgery is a feasible alternative as no increase in complications is observed.

Toxocariasis diagnosed in international travelers at the Institute of Tropical Medicine, Antwerp, Belgium, from 2000 to 2013.

Although infection with Toxocara canis or T. catis (commonly referred as toxocariasis) appears to be highly prevalent in (sub)tropical countries, information on its frequency and presentation in returning travelers and migrants is scarce. In this study, we reviewed all cases of asymptomatic and symptomatic toxocariasis diagnosed during post-travel consultations at the reference travel clinic of the Institute of Tropical Medicine, Antwerp, Belgium. Toxocariasis was considered as highly probable if serum Toxocara-antibodies were detected in combination with symptoms of visceral larva migrans if present, elevated eosinophil count in blood or other relevant fluid and reasonable exclusion of alternative diagnosis, or definitive in case of documented seroconversion. From 2000 to 2013, 190 travelers showed Toxocara-antibodies, of a total of 3436 for whom the test was requested (5.5%). Toxocariasis was diagnosed in 28 cases (23 symptomatic and 5 asymptomatic) including 21 highly probable and 7 definitive. All but one patients were adults. Africa and Asia were the place of acquisition for 10 and 9 cases, respectively. Twelve patients (43%) were short-term travelers (< 1 month). Symptoms, when present, developed during travel or within 8 weeks maximum after return, and included abdominal complaints (11/23 symptomatic patients, 48%), respiratory symptoms and skin abnormalities (10 each, 43%) and fever (9, 39%), often in combination. Two patients were diagnosed with transverse myelitis. At presentation, the median blood eosinophil count was 1720/µL [range: 510-14160] in the 21 symptomatic cases without neurological complication and 2080/µL [range: 1100-2970] in the 5 asymptomatic individuals. All patients recovered either spontaneously or with an anti-helminthic treatment (mostly a 5-day course of albendazole), except both neurological cases who kept sequelae despite repeated treatments and prolonged corticotherapy. Toxocariasis has to be considered in travelers returning from a (sub)tropical stay with varying clinical manifestations or eosinophilia. Prognosis appears favorable with adequate treatment except in case of neurological involvement.

Loiasis with pleural and peritoneal involvement.

We describe a case of atypical loiasis presenting with a chronic pleuroperitoneal effusion in a 50-year-old woman from the Democratic Republic of Congo. Effusions disappeared with conventional treatment and no recurrence was detected after 4 months of follow-up. Such cases of loiasis involving visceral sites have been unusually reported in the literature.