Normothermic regional perfusion in controlled DCD liver procurement: Outcomes of the Swedish national implementation protocol.

Liver transplantation using donors after controlled circulatory death (cDCD) is associated with poorer graft survival and increased incidence of non-anastomotic biliary strictures (NAS) compared to livers procured from brain dead donors (DBD). The use of Normothermic regional perfusion (NRP) during cDCD procurement may improve post-transplant outcome and reduce the incidence of NAS. In Sweden cDCD liver transplantation was introduced through a national pilot protocol with mandatory NRP. This study aims to evaluate the outcome of cDCD liver transplantation during the pilot period. Donor and recipient data were collected on all cDCD liver transplants during the pilot period between 2020 - December 2022. Outcome on NAS, patient- and graft survival, early allograft dysfunction, acute kidney injury, and comprehensive complication index was compared to a matched cohort of 28 patients transplanted with a DBD liver between 2018-2022. 18 patients were transplanted with a liver from a cDCD donor after using NRP. Mean functional warm ischemia time was 29±6 minutes. Mean lactate reduction during NRP was 8.7±2.4 mmol/L, end NRP perfusate ALT was 1.4±1 µkat/L. When comparing cDCD liver transplant recipients to DBD, no significant differences were observed in the incidence of NAS, patient and graft survival, comprehensive complication index, early allograft dysfunction, nor acute kidney injury. Study protocol MRCP in cDCD patients showed no signs of subclinical biliary strictures. Evaluation of the Swedish national pilot of cDCD liver transplantation with mandatory NRP shows comparable outcomes to a matched DBD cohort with 94.4 one-year patient and graft survival and no incidence of NAS within the first year.

Differential hypoxemia and the clinical significance of venous drainage position during extracorporeal membrane oxygenation.

Differential hypoxemia (DH) has been recognized as a clinical problem during veno-arterial extracorporeal membrane oxygenation (VA ECMO) although its features and consequences have not been fully elucidated.This single center retrospective study aimed to investigate the clinical characteristics of patients manifesting DH as well as the impact of repositioning the drainage point from the inferior vena cava (IVC) to the superior vena cava to alleviate DH.All patients (>15 years) commenced on VA ECMO at our center between 2009 and 2020 were screened. Of 472 eligible patients seven were identified with severe DH. All patients had the drainage cannula tip in the IVC or at the junction between the IVC and right atrium.The mean peripheral capillary saturation increased from 54 (±6.6) to 86 (±6.6) %, (p = <0.001) after repositioning of the cannula. Pre-oxygenator saturation increased from 62 (±8.9) % prior to adjustment to 74 (±3.7) %, (p = 0.016) after repositioning. Plasma lactate tended to decrease within 24 h after adjustment. Five patients (71%) survived ECMO treatment, to discharge from hospital, and were alive at 1-year follow-up.Although DH has been described in several studies, the condition has not been investigated in a clinical setting comparing the effect on upper body saturation before and after repositioning of the drainage cannula. This study shows that moving the drainage zone into the upper part of the body has a marked positive effect on upper body saturation in patients with DH.

Six-Month Survival After Extracorporeal Membrane Oxygenation for Severe COVID-19.

OBJECTIVES: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). DESIGN: Multicenter retrospective, observational study. SETTING: Ten tertiary referral university and community hospitals. PARTICIPANTS: Patients with confirmed severe COVID-19-related ARDS. INTERVENTIONS: Venovenous or venoarterial ECMO. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-two patients (mean age 51.1 ± 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 ± 4.4, mean pH was 7.23 ± 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 ± 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 ± 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. CONCLUSIONS: The present findings suggested that about half of adult patients with severe COVID-19-related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. CLINICAL TRIAL REGISTRATION: identifier, NCT04383678.

Extracorporeal Membrane Oxygenation for Septic Shock.

OBJECTIVES: Septic shock carries a high mortality risk. Studies have indicated that patients with septic shock may benefit from extracorporeal membrane oxygenation. In most studies, patients exhibited shock due to myocardial dysfunction rather than distributive/vasoplegic shock. One proposed theory is that venoarterial extracorporeal membrane oxygenation alleviates a failing myocardial function. DESIGN: Retrospective observational study. SETTING: Single-center, high-volume extracorporeal membrane oxygenation unit. PATIENTS: All patients treated for septic shock between 2012 and 2017 with an age greater than 18 years old, fulfilling septic shock criteria according to "Sepsis-3" at acceptance for extracorporeal membrane oxygenation, presence of cardiocirculatory failure requiring a support equivalent to a Vasoactive Inotropic Score greater than 50 to reach a mean arterial pressure greater than 65 mm Hg despite adequate fluid resuscitation, were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-seven patients, mean age 54.7 years old, were included. Median Simplified Acute Physiology Score-3 score was 86 and Sequential Organ Failure Assessment 16. Twenty-seven patients were submitted to venoarterial and 10 patients to venovenous extracorporeal membrane oxygenation. Hospital survival was 90% for septic shock with left ventricular failure and 64.7% in patients with distributive shock. At long-term follow-up at 46.1 months, total survival was 59.5%. Commencement of venovenous extracorporeal membrane oxygenation and more organ failures at admission showed a less favorable outcome in terms of hospital and long-term survival. CONCLUSIONS: The current results add not only to the growing evidence of the benefit of venoarterial extracorporeal membrane oxygenation for septic cardiomyopathy but also indicate improved hospital survival in distributive septic shock.

Patch testing children with aluminium chloride hexahydrate in petrolatum: A review and a recommendation.

BACKGROUND: According to studies on adults, patch testing with aluminium chloride hexahydrate 2% pet. is insufficient to detect aluminium allergy, and a 10% preparation is recommended. Other studies suggest that a 2% preparation is sufficient for testing children. OBJECTIVES: To review three previously published Swedish studies on patch testing children with aluminium chloride hexahydrate 2% pet. PATIENTS/METHODS: Altogether, 601 children with persistent itching subcutaneous nodules (granulomas) induced by aluminium-adsorbed vaccines were patch tested with aluminium chloride hexahydrate 2% pet. and metallic aluminium in (a) a pertussis vaccine trial, (b) clinical practice, and (c) a prospective study. RESULTS: Overall, 459 children had positive reactions to the 2% pet. preparation. Another 10 reacted positively only to metallic aluminium. An extreme positive reaction (+++) was seen in 65% of children aged 1 to 2 years as compared with 22% of children aged 7 years. From 8 years onwards, extreme positive reactions were scarce. CONCLUSIONS: Aluminium chloride hexahydrate 2% pet. is sufficient to trace aluminium allergy in children. Small children are at risk of extreme reactions. We thus suggest that aluminium chloride hexahydrate 10% pet. should not be used routinely in children before the age of 7 to 8 years.

Differential hypoxemia during venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation, indicated for severe cardio-respiratory failure, may result in anatomic regional differences in oxygen saturation. This depends on cannulation, hemodynamic state, and severity of respiratory failure. Differential hypoxemia, often discrete, may cause clinical problems in peripheral femoro-femoral venoarterial extracorporeal membrane oxygenation, when the upper body is perfused with low saturated blood from the heart and the lower body with well-oxygenated extracorporeal membrane oxygenation blood. The key is to diagnose and manage fulminant differential hypoxemia, that is, a state that may develop where the upper body is deprived of oxygen. We summarize physiology, assessment of diagnosis, and management of fulminant differential hypoxemia during venoarterial extracorporeal membrane oxygenation. A possible solution is implantation of an additional jugular venous return cannula. In this article, we propose an even better solution, to drain the venous blood from the superior vena cava. Drainage from the superior vena cava provides superiority to venovenoarterial configuration in terms of physiological rationale, efficiency, safety, and simplicity in clinical circuit design.

Effects of Twice-Weekly Intense Aerobic Exercise in Early Subacute Stroke: A Randomized Controlled Trial.

OBJECTIVE: To examine the effects of 12 weeks of twice-weekly intensive aerobic exercise on physical function and quality of life after subacute stroke. DESIGN: Randomized controlled trial. SETTING: Ambulatory care. PARTICIPANTS: Patients (N=56; 28 women) aged ≥50 years who had a mild stroke (98% ischemic) and were discharged to independent living and enrolled 20 days (median) after stroke onset. INTERVENTIONS: Sixty minutes of group aerobic exercise, including 2 sets of 8 minutes of exercise with intensity up to exertion level 14 or 15 of 20 on the Borg rating of perceived exertion scale, twice weekly for 12 weeks (n=29). The nonintervention group (n=27) received no organized rehabilitation or scheduled physical exercise. MAIN OUTCOME MEASURES: Primary outcome measures included aerobic capacity on the standard ergometer exercise stress test (peak work rate) and walking distance on the 6-minute walk test (6MWT). Secondary outcome measures included maximum walking speed for 10m, balance on the timed Up and Go (TUG) test and single leg stance (SLS), health-related quality of life on the European Quality of Life Scale (EQ-5D), and participation and recovery after stroke on the Stroke Impact Scale (SIS) version 2.0 domains 8 and 9. Participants were evaluated pre- and postintervention. Patient-reported measures were also evaluated at 6-month follow-up. RESULTS: The following improved significantly more in the intervention group (pre- to postintervention): peak work rate (group × time interaction, P=.006), 6MWT (P=.011), maximum walking speed for 10m (P<.001), TUG test (P<.001), SLS right and left (eyes open) (P<.001 and P=.022, respectively), and SLS right (eyes closed) (P=.019). Aerobic exercise was associated with improved EQ-5D scores (visual analog scale, P=.008) and perceived recovery (SIS domain 9, P=.002). These patient-reported improvements persisted at 6-month follow-up. CONCLUSIONS: Intensive aerobic exercise twice weekly early in subacute mild stroke improved aerobic capacity, walking, balance, health-related quality of life, and patient-reported recovery.

Time to eradication of Mycoplasma genitalium after antibiotic treatment in men and women.

OBJECTIVES: The objectives of this study were to evaluate the time to a Mycoplasma genitalium-negative test after start of treatment and to monitor if and when antibiotic resistance developed. METHODS: Sexually transmitted disease (STD) clinic attendees with suspected or verified M. genitalium infection were treated with azithromycin (5 days, 1.5 g; n = 85) or moxifloxacin (n = 5). Subjects with symptomatic urethritis or cervicitis of unknown aetiology were randomized to either doxycycline (n = 49) or 1 g of azithromycin as a single dose (n = 51). Women collected vaginal specimens and men collected first-catch urine 12 times during 4 weeks. Specimens were tested for M. genitalium with a quantitative MgPa PCR and for macrolide resistance-mediating mutations with a PCR targeting 23S rRNA. CLINICAL TRIALS REGISTRATION: NCT01661985. RESULTS: Ninety M. genitalium cases were enrolled. Of 56 patients with macrolide-susceptible strains before treatment with azithromycin (1.5 g, n = 46; 1 g single oral dose, n = 10), 54 (96%) had a negative PCR test within 8 days. In four patients, M. genitalium converted from macrolide susceptible to resistant after a 10 day lag time with negative tests (azithromycin 1.5 g, n = 3; 1 g single oral dose, n = 1). Moxifloxacin-treated subjects (n = 4) were PCR negative within 1 week. Six of eight (75%) remained positive despite doxycycline treatment. CONCLUSIONS: PCR for M. genitalium rapidly became negative after azithromycin treatment. Macrolide-resistant strains were detected after initially negative tests. Test of cure should be recommended no earlier than 3-4 weeks.

How common are long-lasting, intensely itching vaccination granulomas and contact allergy to aluminium induced by currently used pediatric vaccines? A prospective cohort study.

UNLABELLED: The frequency of long-lasting, intensely itching subcutaneous nodules at the injection site for aluminium (Al)-adsorbed vaccines (vaccination granulomas) was investigated in a prospective cohort study comprising 4,758 children who received either a diphtheria-tetanus-pertussis-polio-Haemophilus influenzae type b vaccine (Infanrix®, Pentavac®) alone or concomitant with a pneumococcal conjugate (Prevenar). Both vaccines were adsorbed to an Al adjuvant. Altogether 38 children (0.83 %) with itching granulomas were identified, epicutaneously tested for Al sensitisation and followed yearly. Contact allergy to Al was verified in 85 %. The median duration of symptoms was 22 months in those hitherto recovered. The frequency of granulomas induced by Infanrix® was >0.66 % and by Prevenar >0.35 %. The risk for granulomas increased from 0.63 to 1.18 % when a second Al-adsorbed vaccine was added to the schedule. CONCLUSION: Long-lasting itching vaccination granulomas are poorly understood but more frequent than previously known after infant vaccination with commonly used diphtheria-tetanus-pertussis-polio-Haemophilus influenzae type b and pneumococcal conjugate vaccines. The risk increases with the number of vaccines given. Most children with itching granulomas become contact allergic to aluminium. Itching vaccination granulomas are benign but may be troublesome and should be recognised early in primary health care to avoid unnecessary investigations, anxiety and mistrust.

Severe Lung Dysfunction and Pulmonary Blood Flow during Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is indicated for patients with severe respiratory and/or circulatory failure. The standard technique to visualize the extent of pulmonary damage during ECMO is computed tomography (CT). PURPOSE: This single-center, retrospective study investigated whether pulmonary blood flow (PBF) measured with echocardiography can assist in assessing the extent of pulmonary damage and whether echocardiography and CT findings are associated with patient outcomes. METHODS: All patients (>15 years) commenced on ECMO between 2011 and 2017 with septic shock of pulmonary origin and a treatment time >28 days were screened. Of 277 eligible patients, 9 were identified where both CT and echocardiography had been consecutively performed. RESULTS: CT failed to indicate any differences in viable lung parenchyma within or between survivors and non-survivors at any time during ECMO treatment. Upon initiation of ECMO, the survivors (n = 5) and non-survivors (n = 4) had similar PBF. During a full course of ECMO support, survivors showed no change in PBF (3.8 ± 2.1 at ECMO start vs. 7.9 ± 4.3 L/min, p = 0.12), whereas non-survivors significantly deteriorated in PBF from 3.5 ± 1.0 to 1.0 ± 1.1 L/min (p = 0.029). Tidal volumes were significantly lower over time among the non-survivors, p = 0.047. CONCLUSIONS: In prolonged ECMO for pulmonary septic shock, CT was not found to be effective for the evaluation of pulmonary viability or recovery. This hypothesis-generating investigation supports echocardiography as a tool to predict pulmonary recovery via the assessment of PBF at the early to later stages of ECMO support.

Life-threatening respiratory tract disease with human bocavirus-1 infection in a 4-year-old child.

The disease spectrum associated with human bocavirus-1 infection remains to be fully defined. We report a case of bocavirus-1-associated bronchiolitis, leading to severe respiratory failure and extracorporeal membrane oxygenation in a 4-year-old child, and suggest blood testing for human bocavirus-1 in children with severe respiratory tract infection.

Experiences of the Swedish healthcare system: an interview study with refugees in need of long-term health care.

BACKGROUND: Refugees needing long-term health care must adapt to new healthcare systems. The aim of this study was to examine the viewpoints of nine refugees in a county in Sweden, with a known chronic disease or functional impairment requiring long-term medical care, on their contacts with care providers regarding treatment and personal needs. METHODS: Semi-structured interviews with nine individuals and/or their next of kin. Inductive content analysis was used to identify experiences. RESULTS: ''Care organisations/resources'' and ''professional competence'' were the categories extracted. Participants felt cared for due to accessibility to and regular appointments with the same care provider. Visiting different clinics contributed to a negative experience and lack of trust. The staff 's interest in participants' lives and health contributed to a sense of professionalism. Most participants said the problems experienced were not related to their backgrounds as refugees. Many patients did not fully understand which clinic they were attending or the purpose of the care that the specific clinic provided. Some lacked knowledge of their disease. CONCLUSIONS: Health care was perceived as equal to other Swedish citizens and problems experienced were not explained by refugee backgrounds. Lack of information from care providers and being sent to various levels of care created feelings of a lack of overall medical responsibility.

[Chlamydial infection still a common and sometimes serious infection]. / Klamydia fortfarande vanlig och ibland allvarlig infektion.

Chlamydial infection is the most common bacterial sexually transmitted infection in Sweden and worldwide, despite extensive testing, efficient treatment and partner notification. The incidence of Lymphogranuloma venereum, currently occurring among men who have sex with men and most often in the rectum, shows no tendency to decline. This infection is usually symptomatic but still evading diagnosis due to similarities to other causes of proctitis. There is evidence that rectal chlamydia is common also in women not practicing anal sex.

Conversion from Venovenous to Venoarterial Extracorporeal Membrane Oxygenation in Adults.

No major study has been performed on the conversion from venovenous (VV) to venoarterial (VA) extracorporeal membrane oxygenation (ECMO) in adults. This single-center retrospective cohort study aimed to investigate the incidence, indication, and outcome in patients who converted from VV to VA ECMO. All adult patients (≥18 years) who commenced VV ECMO at our center between 2005 and 2018 were screened. Of 219 VV ECMO patients, 21% (n = 46) were converted to VA ECMO. The indications for conversion were right ventricular failure (RVF) (65%), cardiogenic shock (26%), and other (9%). In the converted patients, there was a significant increase in Sequential Organ Failure Assessment (SOFA) scores between admission 12 (9-13) and conversion 15 (13-17, p < 0.001). Compared to non-converted patients, converted patients also had a higher mortality rate (62% vs. 16%, p < 0.001) and a lower admission Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score (p < 0.001). Outcomes were especially unfavorable in those converted due to RVF. These results indicate that VA ECMO, as opposed to VV ECMO, should be considered as the first mode of choice in patients with respiratory failure and signs of circulatory impairment, especially in those with impaired RV function. For the remaining patients, Pre-admission RESP score, daily echocardiography, and SOFA score trajectories may help in the early identification of those where conversion from VV to VA ECMO is warranted. Multi-centric studies are warranted to validate these findings.

The overall agreement of proposed definitions of mucopurulent cervicitis in women at high risk of Chlamydia infection.

The overall agreement between different criteria for cervicitis in women infected with Chlamydia trachomatis and/or Mycoplasma genitalium, and in women who tested negative was examined. Women attending a clinic for sexually transmitted diseases were enrolled because of sexual partners' suspected chlamydia infection. M. genitalium was tested in a sample of first-catch urine and an endocervical specimen, whereas specimens from four different sites were used for detection of C. trachomatis. Signs of friability and purulent endocervical discharge were documented at gynaecological examination. Specimens for microscopy were taken from the endocervix and urethra as well as the vaginal discharge, and bacterial vaginosis was examined for. The criteria being evaluated included cervical friability and/or pus; polymorphonuclear leukocytes (PMNL)/epithelium cell ratio in the vaginal discharge; and more than 30 PMNL per high-power field in the endocervical smear. The overall agreement of the indicators of cervicitis in women infected with C. trachomatis and/or M. genitalium was 40.5% (15/37), and for those women with negative tests 35.3% (12/34). The criteria for cervicitis require further evaluation, including study of a control group of women at low risk of having a sexually transmitted infection.

Changes in the vaginal microbiota following antibiotic treatment for Mycoplasma genitalium, Chlamydia trachomatis and bacterial vaginosis.

The human vagina harbor a rich microbiota. The optimal state is dominated by lactobacilli that help to maintain health and prevent various diseases. However, the microbiota may rapidly change to a polymicrobial state that has been linked to a number of diseases. In the present study, the temporal changes of the vaginal microbiota in patients treated for sexually transmitted diseases or bacterial vaginosis (BV) and in untreated controls were studied for 26 days. The patients included 52 women treated with azithromycin, tetracyclines or moxifloxacin for present or suspected infection with Chlamydia trachomatis or Mycoplasma genitalium. Women with concurrent BV were also treated with metronidazole. The controls were 10 healthy women of matching age. The microbiota was analyzed by 16S rRNA gene deep sequencing, specific qPCRs and microscopy. There was generally good correlation between Nugent score and community state type (CST) and qPCR confirmed the sequencing results. By sequencing, more than 600 different taxa were found, but only 33 constituted more than 1 ‰ of the sequences. In both patients and controls the microbiota could be divided into three different community state types, CST-I, CST-III and CST-IV. Without metronidazole, the microbiota remained relatively stable regarding CST although changes were seen during menstrual periods. Administration of metronidazole changed the microbiota from CST-IV to CST-III in approximately 50% of the treated patients. In contrast, the CST was generally unaffected by azithromycin or tetracyclines. In 30% of the BV patients, Gardnerella vaginalis was not eradicated by metronidazole. The majority of women colonized with Ureaplasma parvum remained positive after azithromycin while U. urealyticum was eradicated.