[Interdisciplinary ultrasound-guided, minimally invasive autopsy in COVID-19-deceased patients in the intensive care unit of a university hospital : A proof-of-concept study]. / Interdisziplinäre ultraschallgesteuerte minimal-invasive Autopsie bei COVID-19-Verstorbenen auf der Intensivstation einer Universitätsklinik : Eine Proof-of-Concept-Studie.

In this feasibility study, we carried out in an interdisciplinary team standardised, ultrasound-guided, minimally invasive autopsy (US-MIA) directly at the bedside of patients who died of COVID-19 in the intensive care unit of the Rechts der Isar Hospital of the Technical University Munich (TUM). The aim of the study was to verify the feasibility, time efficiency and infection hygiene aspects of the process, as well as the quality of the tissue samples. Our results show that bedside US-MIA is suitable for obtaining tissue samples before the onset of postmortem autolysis, and that it can also be carried out quickly and safely. The potential of US-MIA, which has gained little recognition so far, deserves special attention in the context of postmortem diagnosis, research and quality assurance. In the future, these strengths of US-MIA could help to lead postmortem diagnosis into the modern age of pathological deep analytics ("omics").

Rapid point-of-care detection of SARS-CoV-2 infection in exhaled breath using ion mobility spectrometry: a pilot study.

BACKGROUND: An effective testing strategy is essential for pandemic control of the novel Coronavirus disease 2019 (COVID-19) caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Breath gas analysis can expand the available toolbox for diagnostic tests by using a rapid, cost-beneficial, high-throughput point-of-care test. We conducted a bi-center clinical pilot study in Germany to evaluate breath gas analysis using multi-capillary column ion mobility spectrometry (MCC-IMS) to detect SARS-CoV-2 infection. METHODS: Between September 23, 2020, and June 11, 2021, breath gas measurements were performed on 380 patients (SARS-CoV-2 real-time polymerase chain reaction (PCR) positive: 186; PCR negative: 194) presenting to the emergency department (ED) with respiratory symptoms. RESULTS: Breath gas analysis using MCC-IMS identified 110 peaks; 54 showed statistically significant differences in peak intensity between the SARS-CoV-2 PCR-negative and PCR-positive groups. A decision tree analysis classification resulted in a sensitivity of 83% and specificity of 86%, but limited robustness to dataset changes. Modest values for the sensitivity (74%) and specificity (52%) were obtained using linear discriminant analysis. A systematic search for peaks led to a sensitivity of 77% and specificity of 67%; however, validation by transferability to other data is questionable. CONCLUSIONS: Despite identifying several peaks by MCC-IMS with significant differences in peak intensity between PCR-negative and PCR-positive samples, finding a classification system that allows reliable differentiation between the two groups proved to be difficult. However, with some modifications to the setup, breath gas analysis using MCC-IMS may be a useful diagnostic toolbox for SARS-CoV-2 infection. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov on September 21, 2020 (NCT04556318; Study-ID: HC-N-H-2004).

Training in vascular trauma surgery for non-vascular surgeons: Vascular trauma surgery skills course.

Background: The experience of general and trauma surgeons in vascular trauma management has decreased with sub-specialization of surgery and working hours restrictions. We introduce a vascular trauma surgery skills course established to train German military surgeons prior to their deployment to conflict areas. Methods: The intention and implementation of the vascular trauma course for non-vascular surgeons is described in detail. Results: In hands-on courses, participants learn and train basic vascular surgical techniques on more realistic extremity, neck, and abdominal models with pulsatile vessels. A fundamental and an advanced course each provide military as well as civilian surgeons from different non-vascular specialties with a surgical skill set including direct vessel sutures, patch angioplasty, anastomosis, thrombectomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in order to render them capable of managing major vascular injuries. Conclusion: The experiences of this vascular trauma surgical skills course, initially established for military surgeons, can also be of use to all civilian general, visceral, and trauma surgeons occasionally facing traumatic or iatrogenic vascular injuries. Thus, the introduced vascular trauma course is valuable for all surgeons working in trauma centers.

Adjunctive Hydrocortisone Improves Hemodynamics in Critically Ill Patients with Septic Shock: An Observational Study Using Transpulmonary Thermodilution.

Introduction: Septic shock is associated with high mortality and hemodynamic impairment. The use of corticoids is a common therapeutic tool in critically ill patients. However, data on the mechanisms and prognostic ability of hemodynamic improvement by adjunctive steroids are rare. This study primarily aimed to evaluate short-term effects of hydrocortisone therapy on catecholamine requirement and hemodynamics derived from transpulmonary thermodilution (TPTD) in 30 critically ill patients with septic shock and a 28 days mortality rate of 50%. Methods: Hydrocortisone was administered with an intravenous bolus of 200 mg, followed by a continuous infusion of 200 mg per 24 h. Hemodynamic assessment was performed immediately before as well as 2, 8, 16, and 24 h after the initiation of corticoids. For primary endpoint analysis, we evaluated the impact of hydrocortisone on vasopressor dependency index (VDI) and cardiac power index (CPI). Results: Adjunctive hydrocortisone induced significant decreases of VDI from 0.41 (0.29-0.49) mmHg-1 at baseline to 0.35 (0.25-0.46) after 2 h (P < .001), 0.24 (0.12-0.35) after 8 h (P < .001), 0.18 (0.09-0.24) after 16 h (P < .001) and 0.11 (0.06-0.20) mmHg-1 after 24 h (P < .001). In parallel, we found an improvement in CPI from 0.63 (0.50-0.83) W/m2 at baseline to 0.68 (0.54-0.85) after 2 h (P = .208), 0.71 (0.60-0.90) after 8 h (P = .033), 0.82 (0.6-0.98) after 16 h (P = .004) and 0.90 (0.67-1.07) W/m2 after 24 h (P < .001). Our analyses revealed a significant reduction in noradrenaline requirement in parallel with a moderate increase in mean arterial pressure, systemic vascular resistance index, and cardiac index. As a secondary endpoint, our results showed a significant decrease in lung water parameters. Moreover, changes in CPI (ΔCPI) and VDI (ΔVDI) after 24 h of hydrocortisone therapy revealed accurate prognostic ability to predict 28 days mortality (AUC = 0.802 vs 0.769). Conclusion: Adjunctive hydrocortisone leads to a rapid decrease in catecholamine requirement and a substantial circulatory improvement in critically ill patients with septic shock.

[First case description of contagious ovine digital dermatitis in Switzerland]. / Erstbeschreibung der Krankheit «Kontagiöse ovine digitale Dermatitis¼ in der Schweiz.

INTRODUCTION: Contagious ovine digital dermatitis (CODD) is an emerging infectious foot disease in sheep. To date, CODD has been described in Great Britain, Ireland, Sweden and Germany and now in Switzerland for the first time. Unlike foot rot, the CODD lesions do not spread from the interdigital space, but usually begin at the dorsal/abaxial coronary band. The changes can spread to the hoof wall and the sole and finally can lead to exungulation, similar to foot rot. Treponema spp. are often found in CODD lesions analogous to digital dermatitis (Mortellaro's disease) in cattle. Involvement of Dichelobacter nodosus (D. nodosus) is considered a risk factor, but the presence of the bacterium is not mandatory. In February 2022, ulcerative lesions in the dorso-axial coronary band area were noticed on both claws of the left forelimb in an ewe. Histology of the biopsy showed hyperkeratosis and erosion with exocytosis and crust formation. Treponema spp. PCR and fluorescence in situ hybridization (FISH) were positive for Treponema phylotype 1 (PT1). In addition, D. nodosus and Porphyromonas levii could be detected in the biopsy using PCR. A single local application of chlortetracycline spray led to clinical healing within two weeks, no recurrence was seen within the following two months. Three control sheep, which were kept together with the diseased sheep, did not show any clinical signs of CODD. Treponema spp could not be found in interdigital and coronary band biopsies by PCR or FISH. This is the first description of CODD in Switzerland and aims to sensitize veterinarians to CODD as a differential diagnosis for foot diseases in sheep.

INTRODUCTION: La dermatite digitale contagieuse ovine (contagious ovine digital dermatitis; CODD) est une maladie infectieuse des onglons des moutons d'importance croissante. À ce jour, la CODD a été décrite en Grande-Bretagne, Irlande, Suède et Allemagne, et maintenant pour la première fois également en Suisse. Au contraire du piétain, les lésions de CODD ne s'étendent pas à partir de l'espace interdigité, mais elles commencent en général au bord coronaire dorsal/abaxial. De là, les lésions peuvent s'étendre à la corne de la paroi et à la sole, ce qui peut finalement conduire à une perte complète de la boite cornée de l'onglon, comme en cas de piétain. En analogie à la dermatite digitale (maladie de Mortellaro) chez les bovins, des tréponèmes sont souvent mis en évidence dans les lésions de CODD. La présence de Dichelobacter nodosus (D. nodosus) est considérée comme un facteur de risque, mais elle n'est pas indispensable au développement de la CODD. Des lésions ulcératives dans la région du bord coronaire dorso-axial des deux onglons antérieurs d'une brebis ont été remarqués en février 2022. L'examen histologique de la biopsie de la lésion de CODD a montré une hyperkératose ainsi que des érosions avec de l'exocytose et la formation de croûtes. Aussi bien la PCR pour les Treponema spp. que l'hybridisation in-situ à fluorescence (FISH) étaient positives pour Treponema Phylotype 1 (PT1). De plus, D. nodosus et Porphyromonas levii ont été mis en évidence dans la biopsie. Une application locale unique de spray à la tétracycline après le prélèvement de la biopsie a conduit à une guérison clinique en deux semaines, et aucune récidive n'a été observée dans le deux mois suivants. Trois moutons de boucherie qui étaient détenus avec la brebis malade mais ne présentaient pas de lésions de CODD ont servi de contrôles négatifs. Des Treponema spp. n'ont été mis en évidence chez ces animaux, ni dans des biopsies du bord coronaire ni dans celles de l'espace interdigité. Cette étude représente la première description de la CODD en Suisse et est destinée à sensibiliser la profession vétérinaire à la CODD comme diagnostic différentel en cas de maladies des onglons chez les moutons.

Analysis of a novel hydrophobic acrylic enhanced monofocal intraocular lens compared to its standard monofocal type on the optical bench.

INTRODUCTION: The aim of this laboratory study is to objectively analyze the new hydrophobic, acrylic, enhanced monofocal intraocular lens Acunex Quantum (AN6Q) and compare it with the monofocal platform Acunex AN6.  METHODS: Two IOL models were analyzed (Acunex Quantum AN6Q and Acunex AN6, Teleon Surgical, Spankeren, Netherlands), each having the same refractive power of + 22.0 D, on the optical bench with the OptiSpheric IOL PRO 2. The measurements followed the guidelines of the International Standard Organization with following parameters: ISO 2 cornea (+ 0,28 µ), ISO 11979/2, lens placement in situ in NaCl with 35° temperature, 546 nm and selection of different aperture sizes (3.0 mm vs 4.5 mm). The aberrations of each IOL were evaluated by the WaveMaster IOL 2, a high-resolution Shack-Hartmann sensor in reverse projection setup. An in-situ model eye was used according to ISO 11979 in NaCl (n = 1.337) with 546 nm, mask width 4.51. Zernike polynomials up to 10th order were determined by means of the measured wavefront that describe the optical properties of the IOL. RESULTS: Through frequency modulation transfer function (mean) at 50 lp/mm (AN6Q/AN6 centered) was 0.687/0.731 (3.0 mm aperture) and 0.400/0.509 (4.5 mm aperture). The SR (mean) was 0.592/0.809 (3.0 mm) and 0.332/0.372 (4.5 mm). The MTF (mean) at 50 lp/mm (AN6Q/AN6 decentered by 1 mm) was 0.413/0.478 (3.0 mm) and 0.257/0.229 (4.5 mm). The SR (mean) was 0.393/0.404 (3.0 mm) and 0.183/0.212 (4.5 mm). The MTF (mean) at 50 lp/mm (AN6Q/AN6 tilted by 5°) was 0.508/0.710 (3.0 mm) and 0.337/0.513 (4.5 mm). The SR (mean) was 0.508/0.760 (3.0 mm) and 0.235/0.2372 (4.5 mm). AN6Q showed MTF peak of 0.55 with an enlarged depth of power of about 2.5 D and two cusps in the MTF curve. The spherical aberration Z 4-0 was about -0.21 µm and the secondary spherical aberration Z 6-0 was about 0.16 µm. No other relevant aberration showed up. CONCLUSION: The new, enhanced monofocal AN6Q provides an extended range of focus with only slight decrease in contrast quality. Both types of the hydrophobic, acrylic Acunex IOL platform have its particular advantages in clinical settings and therefore its importance, respectively.

Clinical characteristics and outcome of patients with enterococcal liver abscess.

Epidemiology of bacteria isolated from pyogenic liver abscesses change, and an increase in enterococci has been reported in European hospitals. The aim of this study was to investigate the clinical characteristics and outcome of enterococcal PLA. We performed a retrospective analysis of patients with microbiologically confirmed PLA at three German university centers. Indicators of enterococcal PLA were determined using binary logistic regression, and survival analysis was performed using Kaplan-Meier statistics and Cox regression analysis. Enterococci were isolated in 51/133 (38%) patients with PLA. Patients with enterococcal PLA had smaller abscess diameter (4.8 vs. 6.7 cm, p = 0.03) than patients with non-enterococcal PLA, but had more frequent polymicrobial culture results. In univariate logistic regression analysis, alcohol abuse (OR 3.94, 95% CI 1.24-12.49, p = 0.02), hepatobiliary malignancies (OR 3.90, 95% CI 1.86-8.18, p < 0.001) and cirrhosis (OR 6.36, 95% CI 1.27-31.96, p = 0.02) were associated with enterococcal PLA. Patients with enterococcal PLA had a higher mortality than patients with non-enterococcal PLA (hazard ratio 2.92; 95% confidence interval 1.09-7.80; p = 0.03), which remained elevated even after excluding patients with hepatobiliary malignancies, cirrhosis, and transplant recipients in a sensitivity analysis. The increased mortality was associated with non-fecal enterococci but not in patients with Enterococcus faecalis. In this retrospective, multicenter study, enterococcal PLA was common and indicated an increased risk of mortality, underscoring the need for close clinical monitoring and appropriate treatment protocols in these patients.

A proof of concept study for the differentiation of SARS-CoV-2, hCoV-NL63, and IAV-H1N1 in vitro cultures using ion mobility spectrometry.

Rapid, high-throughput diagnostic tests are essential to decelerate the spread of the novel coronavirus disease 2019 (COVID-19) pandemic. While RT-PCR tests performed in centralized laboratories remain the gold standard, rapid point-of-care antigen tests might provide faster results. However, they are associated with markedly reduced sensitivity. Bedside breath gas analysis of volatile organic compounds detected by ion mobility spectrometry (IMS) may enable a quick and sensitive point-of-care testing alternative. In this proof-of-concept study, we investigated whether gas analysis by IMS can discriminate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from other respiratory viruses in an experimental set-up. Repeated gas analyses of air samples collected from the headspace of virus-infected in vitro cultures were performed for 5 days. A three-step decision tree using the intensities of four spectrometry peaks correlating to unidentified volatile organic compounds allowed the correct classification of SARS-CoV-2, human coronavirus-NL63, and influenza A virus H1N1 without misassignment when the calculation was performed with data 3 days post infection. The forward selection assignment model allowed the identification of SARS-CoV-2 with high sensitivity and specificity, with only one of 231 measurements (0.43%) being misclassified. Thus, volatile organic compound analysis by IMS allows highly accurate differentiation of SARS-CoV-2 from other respiratory viruses in an experimental set-up, supporting further research and evaluation in clinical studies.

Practice of radiation therapy for anal cancer in Austria-a survey on behalf of the Austrian radiation oncology society gastrointestinal tumor group (ÖGRO-GIT).

PURPOSE: We conducted a patterns-of-care survey on chemoradiation for locoregionally confined anal cancer in Austria to evaluate areas of disagreement and to identify possible targets for further standardization. METHODS: An anonymous questionnaire comprising 38 questions was sent to all Austrian radiation oncology departments. Results were analyzed descriptively and compared to two international guidelines. RESULTS: The response rate was 93%. Work-up generally includes DRE, endoscopy, and cross-sectional imaging of chest/abdomen and pelvis. PET-CT is used by 38%. Screening for HIV and biopsies of suspicious lymph nodes are infrequently used. All centers perform IMRT, mainly with daily IGRT. Median doses to the primary are 54.7 Gy (T1-2) and 59.4 Gy (T3-4). Suspicious nodes receive a boost (median dose 54 Gy), while elective nodal areas are mainly treated with 45-50.4 Gy. Target delineation of elective nodal areas seems generally uniform, although disagreement exists regarding inclusion of the common iliac nodes. No agreement was found for OAR-delineation and dose constraints. Concurrent chemotherapy is mitomycin and 5­FU/capecitabine. Supportive care beyond skin care is infrequently offered. Intensive follow-up is performed for at least 5 years. Treatment of T1N0 shows considerable disagreement. CONCLUSION: We found a high rate of agreement between the centers and concordance with major guidelines. PET-CT, routine HIV testing, and biopsies of suspicious LN seem underrepresented. The largest controversy regarding target volumes concerns inclusion of the common iliac nodes. Prescribed doses are generally in line with the recommendations or higher. OAR delineation, dose constraints, supportive care, and treatment of early anal cancer represent areas for further standardization.

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]. / EUROCRINE®: Nebennierenoperationen 2015 bis 2019 ­ überraschende erste Ergebnisse.

BACKGROUND: Since 2015 operations performed in the field of endocrine surgery have been entered into the European registry EUROCRINE®. The aim of this analysis was a description of the current healthcare situation for adrenal surgery in a homogeneous healthcare environment corresponding to the German-speaking countries-or to the presence of the working group on surgical endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)-and to assess the adherence to current international treatment guidelines. METHODS: An analysis of the preoperative diagnostics, the applied operative techniques and the underlying histological entities was carried out for all operations on adrenal glands in Germany, Switzerland and Austria, which were registered in EUROCRINE® from 2015 to 2019. RESULTS: In the total of 21 participating hospitals from the German-speaking EUROCRINE® countries, 658 operations on adrenal glands were performed. In 90% of cases unilateral adrenalectomy was performed, in 3% bilateral adrenalectomy and in 7% other resection procedures. In 41% the main histological diagnosis was an adrenocortical adenoma. In 15% malignant entities were detected on final histology, including 6% adrenocortical carcinoma (ACC) and 8% metastases to the adrenal glands. 23% of the operations were performed for pheochromocytoma. This entity was primarily resected using minimally invasive approaches (82%), whereas minimally invasive techniques were applied in 28% for ACC and in 66% for metastases to the adrenal glands. CONCLUSION: Surprisingly, following adrenocortical adenoma and pheochromocytoma, the third most common histological entity was metastasis of different extra-adrenal primary tumors to the adrenal gland. Of the operations for ACC 28% were scheduled for minimally invasive techniques, but conversion to open surgery was necessary in 20%. The analysis revealed discrepancies between treatment reality and international guideline recommendations that raise questions, which will be addressed by an updated version of the EUROCRINE® module for the documentation of adrenal surgery.

[Oestrus suppression in a dairy herd by means of anti-GnRH vaccination Improvac®: A prospective field study]. / Brunstunterdrückung mittels Anti-GnRH-Impfung Improvac® in einem Milchviehbestand: Eine prospektive Feldstudie.

INTRODUCTION: The aim of this study was to evaluate the duration of estrus suppression after a double administration of the anti-GnRH vaccine Improvac® (Zoetis Schweiz GmbH, 2800 Delémont) in cows. Furthermore, it should be investigated, if a third administration could prolong the effect of the cycle suppression. A total of 21 cows (more than four weeks post partum) were vaccinated twice, at least 35 days apart, with 2 ml Improvac® (0.4 mg of a GnRH-analogon) subcutaneously on one side of the neck. Over a period of 368 days and in the course of 18 farm visits these cows were examined gynecologically and re-vaccinated if they showed signs of estrus behaviour or ovarian activity. After the second vaccination the cycle of the cows was suppressed for an average period of 114 days (59-175 days) and the effect could be prolonged by a booster of the vaccine for another 127 days in three cows. Estrus behaviour was absent for a longer period than ovarian activity was. The vaccine was tolerated well: apart from slight swelling at the injection site, no side effects were observed. Our results demonstrate that two immunizations with Improvac® are an easily applicable method for the suppression of cyclic activity in cows for a mean period of 114 days. The duration of cycle suppression was prolonged by a booster of the vaccination.

INTRODUCTION: Le but de cette étude était d'évaluer la durée de la suppression des chaleurs chez les vaches après une double administration du vaccin anti-GnRH Improvac® (Zoetis Schweiz GmbH, 2800 Delémont). En outre, on a recherché si une troisième administration pourrait prolonger l'effet de la suppression du cycle. Au total, 21 vaches (plus de quatre semaines après vèlage) ont été vaccinées deux fois, à au moins 35 jours d'intervalle, avec 2 ml d'Improvac® (0,4 mg d'analogue de la GnRH) par voie sous-cutanée d'un côté du cou. Sur une période de 368 jours et au cours de 18 visites à la ferme, ces vaches ont été examinées gynécologiquement et revaccinées si elles présentaient des signes de comportement œstral ou d'activité ovarienne. Après la deuxième vaccination, le cycle des vaches a été supprimé pendant une période moyenne de 114 jours (59 - 175 jours) et l'effet a pu être prolongé par un rappel du vaccin pendant 127 jours supplémentaires chez trois vaches. Le comportement d'œstrus était absent pendant une période plus longue que l'inactivité ovarienne. Le vaccin a été bien toléré: à part une légère enflure au site d'injection, aucun effet secondaire n'a été observé. Nos résultats démontrent que deux immunisations avec Improvac® sont une méthode facilement applicable pour la suppression de l'activité cyclique chez les vaches pendant une période moyenne de 114 jours. La durée de la suppression du cycle a été prolongée par un rappel de vaccination.

A rare case of perivascular epithelioid cell tumor (PEComa) of the pancreas diagnosed by endoscopic ultrasound.

A 49-year-old woman consulted her general practitioner (GP) regarding epigastric pain that she had experienced for 2 months. Physical examination and laboratory results were unremarkable. An abdominal ultrasound indicated a solid pancreatic tumor, which was confirmed on subsequent CT and MRI. Endoscopic ultrasound (EUS) showed a well-defined heterogeneous, predominantly hypoechoic mass in the pancreatic body, so a neuroendocrine tumor (NET) was suspected. However, EUS-guided fine-needle aspiration (EUS-FNA) was performed and based on (immuno-)histochemical findings, the extremely rare diagnosis of a perivascular epithelioid cell tumor (PEComa) of the pancreas was made. Due to the malignant potential of pancreatic PEComas, laparoscopic left-sided pancreatectomy was performed. We present a case diagnosed by preoperative EUS-FNA highlighting the clinical and endosonographic features which help to distinguish it from its most important differential diagnosis, neuroendocrine tumors (NETs) of the pancreas.

Changes in gut microbial metagenomic pathways associated with clinical outcomes after the elimination of malabsorbed sugars in an IBS cohort.

Specific diets to manage sugar malabsorption are reported to reduce clinical symptoms of irritable bowel syndrome (IBS). However, the effects of diets for malabsorbed sugars on gut microbiota signatures have not been studied, and associations with clinical outcomes in IBS have not been characterized. 22 IBS patients positively tested for either lactose-, fructose-, sorbitol- or combined malabsorptions were subjected to 2-weeks sugar elimination and subsequent 4-weeks re-introduction. 7 IBS patients tested negative for sugar malabsorption were used as controls. Nutrition and clinical symptoms were recorded throughout the study. Fecal samples were serially collected for 16S rRNA amplicon and shotgun-metagenome sequencing. Dietary intervention supervised by nutrition counseling reduced IBS symptoms during the elimination and tolerance phases. Varying clinical response rates were observed between subjects, and used to dichotomize our cohort into visual analogue scale (VAS) responders and non-responders. Alpha -and beta-diversity analyzes revealed only minor differences regarding 16S rRNA-based fecal microbiota compositions between responder and non-responder patients during baseline or tolerance phase. In shotgun-metagenome analyzes, however, we analyzed microbial metabolic pathways and found significant differences in pathways encoding starch degradation and complex amino acid biosynthesis at baseline between IBS controls and malabsorbers, and notably, between diet responder and non-responders. Faecalibacterium prausnitzii, Ruminococcus spp. and Bifidobacterium longum largely informed these metabolic pathways. Our study demonstrates that diet interventions for specific, malabsorbed carbohydrates reshaped the metagenomic composition of the gut microbiota, with a small community of bacterial taxa contributing to these changes rather than a single species.

A retrospective clinical and microbial analysis of 32 patients with bilomas.

BACKGROUND: Bilomas are defined collections of bile fluids mainly caused by iatrogenic injuries of the bile duct system. Owing to the infrequency of this disease, studies addressing bilomas are rare. METHODS: By using an endoscopic database, this retrospective study identified 32 patients with bilomas treated between 2004 to 2015, in order to analyse aetiology, clinical presentation, spectrum of pathogens, and resolution rate of bilomas. RESULTS: 65.6% of the study population (21/32) developed bilomas after surgery and 21.9% (7/32) after endoscopic retrograde cholangiography (ERC). Icterus, fever, and abdominal pain were the leading symptoms. 93.9% (46/49) of microbiological bile cultures revealed a positive microbiology. The predominant microorganisms were the group of Enterobacteriaceae (43.0%, 52/121), followed by Enterococcus spp. (32.2%, 39/121), and Candida spp. (9.1%, 11/121). Multiresistant bacteria like Enterobacteriaceae were isolated from one quarter of all patients. Single or multimodal treatment resulted in an overall complication rate of 4.8% (9/188). Clinical follow-up analysis showed a complete resolution rate of 78.3% for interventional therapy and 80% in the non-interventional group. CONCLUSIONS: Pathogen spectrum of bilomas mainly comprises the group of Enterobacteriacae and Enterococcus spp., with a high proportion of multiresistant bacteria. Different interventional approaches are available for biloma drainage, which seem to be safe and effective for most patients. TRIAL REGISTRATION: German Clinical Trials Register DRKS00015208 , retrospectively registered.

Adherence to subcutaneous interferon beta-1a treatment using an electronic injection device: a prospective open-label Scandinavian noninterventional study (the ScanSmart study).

BACKGROUND: Disease modifying drugs help control the course of relapsing remitting multiple sclerosis (RRMS); however, good adherence is needed for long-term outcomes. OBJECTIVE: To evaluate patient adherence to treatment with subcutaneous interferon beta-1a using RebiSmart® and assess injection-site reactions and treatment satisfaction. METHODS: This prospective, single-arm, open-label, noninterventional multicenter Phase IV trial included disease modifying drug-experienced mobile patients with RRMS. Adherence was measured over 12 weeks. Items 13-23, 35, 37, and 38 of the Multiple Sclerosis Treatment Concerns Questionnaire (injection-site reactions and treatment satisfaction) were recorded at 12 weeks. RESULTS: Sixty patients were recruited (mean age 43.7 [±SD 7.9] years; 83% female; mean years since multiple sclerosis diagnosis 6.7 [SD 4.5]). Adherence data were obtained in 54 patients only due to technical problems with six devices. Over 12 weeks, 89% (n=48) of patients had ≥90% adherence to treatment. Most patients experienced mild influenza-like symptoms and injection-site reactions, and global side effects were minimal. Most patients (78%) rated the convenience as the most important aspect of the device, and most experienced no or mild pain. CONCLUSION: RRMS patients treated with subcutaneous interferon beta-1a, administered with RebiSmart, demonstrated generally good adherence, and the treatment was generally well tolerated.

[Retrieval of a migrated plastic stent in a 51-year-old man]. / Bergung eines migrierten Doppel-Pigtail-Stents bei einem 51-jährigen Patienten.

BACKGROUND: Endosonographically guided transgastric drainage is the first-line interventional therapy of walled-off necrosis and symptomatic pancreatic pseudocysts in necrotizing pancreatitis. Plastic stents or lumen apposing metal stents are commonly used. A possible complication of endoscopic therapy is stent migration. CASE REPORT: We report upon a 51-year-old man who presented with acute necrotizing pancreatitis. Transgastric necrosectomy was performed and 5 transmural double-pigtail stents (DPS) were left in situ to drain the residual retroperitoneal cavity. The patient recovered and 4 stents were endoscopically removed 5 weeks later on an outpatient basis, whereas the fifth stent was suspected to have passed spontaneously via the natural route. The asymptomatic patient presented 3 months later for follow-up computed tomography. The necrosis had healed but one DPS was seen beyond the gastric wall near the kidney. Transmural access to the stent could be achieved by an endosonographically guided puncture toward the proximal portion of the stent followed by placement of a hydrophilic guidewire alongside the stent. A new gastrostomy was created by using a 6F cystotome followed by wire-guided dilation with a 12 mm balloon. The stent could then be grasped with transmurally inserted rat-tooth forceps and repositioned across the gastrostomy site. The patient was given prophylactic antibiotics. After removal of the stent, the patient could be discharged. CONCLUSION: Herein, we present the successful endosonographically guided transmural removal of a retroperitoneally migrated plastic stent. Of note, in our patient we had to rely completely on endosonography and radiography for localization and targeting of the stent, since the former necrotic cavity had meanwhile completely healed.

Relationship between polarities of antibiotic and polymer matrix on nanoparticle formulations based on aliphatic polyesters.

In the field of nanomedicine, nanoparticles are developed to target antibiotics to sites of bacterial infection thus enabling adequate drug exposure and decrease development of resistant bacteria. In the present study, we investigated the encapsulation of two antibiotics with different polarity into different PEGylated polymeric nanoparticles based on aliphatic polyesters, to obtain a better understanding of critical factors determining encapsulation and release. The nanoparticles were prepared from diblock copolymers comprising of a poly(ethylene glycol) block attached to an aliphatic polyester block of varying polarity: poly(lactic-co-glycolic acid) (mPEG-PLGA), poly(lactic-co-hydroxymethyl glycolic acid) (mPEG-PLHMGA) and poly(lactic-co-benzyloxymethyl glycolic acid) (mPEG-PLBMGA). Hydrophobic bedaquiline and hydrophilic vancomycin were encapsulated via single and double-emulsion solvent evaporation techniques, respectively. Encapsulation, degradation and release studies at physiological simulating conditions were performed. Drug polarity and preparation techniques influenced encapsulation efficiency into polymer nanoparticles, giving almost complete encapsulation of bedaquiline and approx. 30% for vancomycin independent of the polymer type. The nonpolar bedaquiline showed a predominantly diffusion-controlled release independent of polymer composition. However, polar vancomycin was released by a combination of diffusion and polymer degradation, which was significantly affected by polymer composition, the most hydrophilic polymer displaying the fastest release.

First description of spontaneous fungal peritonitis caused by Fusarium solani in a critically ill patient with liver cirrhosis.

Fusarium spp., common soil moulds, are emerging fungal pathogens in immunocompromised subjects. We report the first case of Fusarium solani peritonitis in a patient with liver cirrhosis. Because of the high morbidity and mortality associated with fusariosis, an aggressive approach to treatment as well as identification of the species and drug susceptibilities is warranted.

Endoscopic rendez-vous reconstruction of complete biliary obstruction.

BACKGROUND AND STUDY AIMS: Complete biliary strictures normally require surgical intervention. We describe an alternative, minimally invasive endoscopic/percutaneous rendez-vous technique for the reconstruction of complete benign biliary strictures. PATIENTS AND METHODS: Complete biliary strictures were reconstructed in four patients using a rendez-vous percutaneous-endoscopic or percutaneous-percutaneous route guided by fluoroscopic and visual (transillumination) control. RESULTS: All four patients were treated successfully and safely with the rendez-vous technique. Complications were caused by the preliminary creation, dilatation and maturation of the percutaneous tract. CONCLUSION: This technique may offer a good alternative to surgical bilio-enteric anastomosis in experienced hands. The long term course of the patients treated remains to be seen.