Culture-Negative Neutrocytic Ascites in a Patient With Cardiac Ascites From End-Stage Heart Failure.

There are two significant groups of infection regarding ascitic fluid: spontaneous bacterial peritonitis (SBP) and culture-negative neutrocytic ascites (CNNA). SBP and CNNA typically occur in patients with cirrhosis. A 46-year-old male with end-stage biventricular heart failure presented with a heart failure exacerbation. He was treated with intravenous diuretics with the improvement of hypervolemia. He remained hospitalized to undergo an evaluation for tricuspid valve repair, but given the severity of his bi-ventricular heart failure, he underwent a heart transplant evaluation. As part of the work-up, he underwent an abdominal ultrasound that was significant for severe ascites but did not note an abnormal hepatic architecture suggestive of cirrhosis. A liver biopsy was then performed, which confirmed no evidence of cirrhosis. His hospitalization was complicated by refractory cardiac ascites, which required a bi-weekly paracentesis. The serum albumin-ascites gradient (SAAG) from his initial paracentesis was 1.4, indicating the etiology was from portal hypertension. The total protein was greater than 2.5 in multiple studies, so the etiology was less concerning for cirrhosis and secondary to his heart failure. About two weeks into his hospital course, he developed a leukocytosis but remained hemodynamically stable and asymptomatic from an infectious standpoint. Analysis of his ascitic fluid initially was negative for infection, but he later developed an elevated total neutrophil count on a subsequent ascitic fluid analysis study. The body fluid culture remained negative for bacterial growth. Hepatology was consulted, and he met the criteria for CNNA, so treatment with ceftriaxone was initiated. After initiating antibiotics, his leukocytosis and elevated ascitic fluid total neutrophil count resolved. Ascitic infections such as CNNA generally occur in patients with liver cirrhosis but may occur in patients without cirrhosis, as observed in our patient. This case highlights that patients with cardiac ascites can develop ascitic fluid infections that may have an impact on their mortality. The precipitating factor that enabled the patient to develop CNNA is unclear but may be related to the translocation of bacteria during his congestive heart failure exacerbation. Although uncommon in a patient with cardiac ascites, an early diagnosis of CNNA and the initiation of antibiotics can be important in preventing patient mortality.

Pyloric Functional Lumen Imaging Probe Measurements Are Dependent on Balloon Position.

Background/Aims: The functional lumen imaging probe (FLIP) device has been used to assess pyloric dysfunction in patients with gastroparesis. We aim to investigate whether varying FLIP catheter positions affect pyloric FLIP measurements. Methods: Patients undergoing endoscopy for chronic unexplained nausea and vomiting (CUNV) or gastroparesis were prospectively enrolled. FLIP balloon was adjusted for 3 positions within the pylorus: (1) proximal position, 75% of FLIP balloon in the duodenum and 25% in the antrum; (2) middle position, 50% in the duodenum and 50% in the antrum; and (3) distal position, 25% in the duodenum and 75% in the antrum. Pylorus cross-sectional area (CSA), intra-bag pressure (P), and distensibility indices (DI) were measured for 30, 40, and 50-mL balloon volumes. Fluoroscopic images were obtained to confirm FLIP balloon geometry. Data was analyzed separately using FLIP Analytic and customized MATLAB software. Results: Twenty-two patients with CUNV (n = 4) and gastroparesis (n = 18) were enrolled. Pressures were significantly higher in the proximal position compared to the middle and distal positions. CSA measurements were significantly higher at the proximal and middle positions for 30-mL and 40-mL volume compared to the distal position values. DI values were significantly lower at the proximal positions for 40-mL and 50-mL distensions when compared to the middle and distal positions. Fluoroscopic images confirmed increased balloon bending when placed mostly in the duodenum. Conclusions: FLIP balloon position within the pylorus directly affects balloon geometry which significantly affects P, CSA, and DI measurements. Standardized pyloric FLIP protocols and balloon design adjustments are needed for the continued application of this technology to the pylorus.

Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: a prospective single-center experience with mid-term follow-up (with video).

BACKGROUND AND AIMS: Gastroparesis (GP) is a multifactorial disease associated with a large burden on the health care systems. Pyloric-directed therapies including gastric peroral endoscopic myotomy (G-POEM) can be effective in improving patient quality of life and symptom severity. We report on the safety and efficacy of G-POEM and its impact on the quality of life of patients managed at a large referral center. METHODS: Consecutive patients with confirmed GP referred for G-POEM due to failure of medical therapy were included. All patients were assessed at baseline and then at 1, 3, 6, and 12 and 24 months after G-POEM using validated symptom and quality of life instruments, including the Gastroparesis Cardinal Symptom Index (GCSI), Patient Assessment of Gastrointestinal Disorders Symptom Severity Index (PAGI-SYM), and 36-Item Short Form Survey (SF-36). Patients were evaluated before and 6 months after the procedure with EGD, 4-hour scintigraphy, and pyloric EndoFLIP. Technical success was defined as the ability to perform full-thickness pyloromyotomy. Clinical response was defined as an improvement of ≥1 point on GCSI. RESULTS: Fifty-two patients (median age, 48 years; range, 25-80 years, 88% female) underwent G-POEM between February 2018 and September 2020 for the following phenotypes: vomiting-predominant (n=30), dyspepsia-predominant (n=16), and regurgitation-predominant (n=6) GP. The technical success rate was 100%. Adverse events were noted in 3 of 52 patients (5.77%), and were all managed successfully endoscopically. Clinical response was achieved in 68%, 58%, and 48% of patients at 1-month, 6-month, and 12-month follow-up (P < .001, P < .001, and P < .01, respectively). When classified by the cause of GP, the clinical response rates were diabetic GP 64% (11 of 17), postsurgical GP 67% (6 of 9), and idiopathic GP 72% (13 of 18). A statistically significant improvement in PAGI-SYM scores was observed at 1, 3, 6, 12, and 24 months, in addition to significant improvement in several domains of SF-36. Mean 4-hour gastric emptying was reduced 6 months after G-POEM (10.2%) compared with baseline (36.5%, P < .001). We report a significant reduction in the number of emergency department visits and days spent in the hospital up to 24 months after G-POEM. CONCLUSIONS: G-POEM appears to be a safe and feasible treatment alternative for refractory GP with significant short-term and mid-term improvements in overall symptoms, quality of life scores, and health care utilization.

Graphene Derivative in Magnetically Recoverable Catalyst Determines Catalytic Properties in Transfer Hydrogenation of Nitroarenes to Anilines with 2-Propanol.

Here, we report transfer hydrogenation of nitroarenes to aminoarenes using 2-propanol as a hydrogen source and Ag-containing magnetically recoverable catalysts based on partially reduced graphene oxide (pRGO) sheets. X-ray diffraction and X-ray photoelectron spectroscopy data demonstrated that, during the one-pot catalyst synthesis, formation of magnetite nanoparticles (NPs) is accompanied by the reduction of graphene oxide (GO) to pRGO. The formation of Ag0 NPs on top of magnetite nanoparticles does not change the pRGO structure. At the same time, the catalyst structure is further modified during the transfer hydrogenation, leading to a noticeable increase of sp2 carbons. These carbons are responsible for the adsorption of substrate and intermediates, facilitating a hydrogen transfer from Ag NPs and creating synergy between the components of the catalyst. The nitroarenes with electron withdrawing and electron donating substituents allow for excellent yields of aniline derivatives with high regio and chemoselectivity, indicating that the reaction is not disfavored by these functionalities. The versatility of the catalyst synthetic protocol was demonstrated by a synthesis of an Ru-containing graphene derivative based catalyst, also allowing for efficient transfer hydrogenation. Easy magnetic separation and stable catalyst performance in the transfer hydrogenation make this catalyst promising for future applications.

Facile Synthesis of Magnetically Recoverable Pd and Ru Catalysts for 4-Nitrophenol Reduction: Identifying Key Factors.

This paper reports the development of robust Pd- and Ru-containing magnetically recoverable catalysts in a one-pot procedure using commercially available, branched polyethyleneimine (PEI) as capping and reducing agent. For both catalytic metals, ∼3 nm nanoparticles (NPs) are stabilized in the PEI shell of magnetite NPs, whose aggregation allows for prompt magnetic separation. The catalyst properties were studied in a model reaction of 4-nitrophenol hydrogenation to 4-aminophenol with NaBH4. A similar catalytic NP size allowed us to decouple the NP size impact on the catalytic performance from other parameters and to follow the influence of the catalytic metal type and amount as well as the PEI amount on the catalytic activity. The best catalytic performances, the 1.2 min-1 rate constant and the 433.2 min-1 turnover frequency, are obtained for the Ru-containing catalyst. This is discussed in terms of stability of Ru hydride facilitating the surface-hydrogen transfer and the presence of Ru4+ species on the Ru NP surface facilitating the nitro group adsorption, both leading to an increased catalyst efficiency. High catalytic activity as well as the high stability of the catalyst performance in five consecutive catalytic cycles after magnetic separation makes this catalyst promising for nitroarene hydrogenation reactions.