Infections in Cirrhosis: A Guide for the Clinician

Cirrhosis contributes significantly to morbidity and mortality worldwide. Infections in patients with cirrhosis are common and significantly impact health-related quality of life. As our understanding of immune dysfunction associated with cirrhosis grows and as rates of drug-resistant organisms increase, the management of infections in cirrhosis has become increasingly nuanced. In this review, we discuss the current understanding of cirrhosis-associated immune deficiency, review the most common infections in patients with cirrhosis, and highlight techniques for the general clinician in the prevention and treatment of infections in this high-risk population.     

Peripherally Inserted Central Catheter Thrombosis After Placement via Electrocardiography vs Traditional Methods

BackgroundPeripherally inserted central catheter tip placement at the cavoatrial junction is associated with reduced catheter-related deep vein thrombosis. Electrocardiographic tip confirmation purportedly improves accuracy of tip placement, but whether this approach can reduce deep vein thrombosis is unknown.MethodsProspectively collected data from patients that received peripherally inserted central catheters at 52 Michigan hospitals were analyzed. The method used to confirm tip confirmation at insertion and deep vein thrombosis outcomes were extracted from medical records. Multivariate models (accounting for the clustered nature of the data) were fitted to assess the association between peripherally inserted central catheter-related deep vein thrombosis and method of tip confirmation (electrocardiographic vs radiographic imaging).ResultsA total of 42,687 peripherally inserted central catheters (21,098 radiology vs 21,589 electrocardiographic) were included. Patients receiving electrocardiographic-confirmed peripherally inserted central catheters had fewer comorbidities compared with those that underwent placement via radiology. Overall, deep vein thrombosis occurred in 594 (1.3%) of all peripherally inserted central catheters. Larger catheter size (odds radio [OR] 1.32; 95% confidence interval [CI], 0.93-1.90 per unit increase in gauge), history of deep vein thrombosis, and cancer were associated with increased risk of deep vein thrombosis (OR 2.00; 95% CI, 1.65-2.43 and OR 1.62; 95% CI, 1.16-2.26, respectively) using logistic regression. Following adjustment, electrocardiographic guidance was associated with a significant reduction in peripherally inserted central catheter-related deep vein thrombosis compared with radiographic imaging (OR 0.74; 95% CI, 0.58-0.93; P = .0098).ConclusionThe use of electrocardiography to confirm peripherally inserted central catheter tip placement at the cavoatrial junction was associated with significantly fewer deep vein thrombosis events than radiographic imaging. Use of this approach for peripherally inserted central catheter insertion may help improve patient safety, particularly in high-risk patients.     

Cost‐effective screening method for antinuclear antibody detection

Aim: To evaluate indirect immunoenzyme (IIE) technique, for detection of antinuclear antibodies (ANA) using serum and filter paper blood clots (FPBC) especially for screening. Methods: Antinuclear antibody processing from FPBC (prepared by expressing blood drops by finger pricking) was standardized in a pilot study. Paired samples (serum and corresponding FPBC) from 224 individuals [142 patients of systemic rheumatic diseases, chiefly lupus and rheumatoid arthritis (RA) and 82 healthy controls (HC)] were tested by the standard immunofluorescence (IIF) and IIE (using light microscope); samples were coded, blinded and randomly processed as per the protocol. End‐point titres were determined for positive serum samples only. Standard reagents (Immunoconcepts Incorporation, US) and controls (CDC, Atlanta, US) were used. All patients were identified in a rheumatology referral practice in an Indian metropolis. Results: The sensitivity of IIE and IIF for SLE, using serum and FPBC was ≈90%. The specificity of IIE and IIF for SLE, using serum and FPBC was in the range 66–73% and 58–63%, respectively. Good–perfect agreement (κ > 0.8) between the results was obtained by IIE and IIF for all groups except RA. Except the RA group, all other paired samples showed good concordance (72%) on testing for ANA patterns by both techniques. Conclusions: Indirect immunoenzyme technique is a robust technique and should be considered a viable option to IIF at least in countries like India; its further use on FPBC is a socioeconomically appealing proposition for carrying out population studies on lupus and related uncommon connective tissue disorders.     

Side population/ABCG2-positive cells represent a heterogeneous group of haemopoietic cells: implications for the use of adult stem cells in transplantation and plasticity protocols

Murine side population (SP) cells may have an increased ability to engraft lethally irradiated mice and lack CD34 expression. Strategies using CD34 as a primary marker of haemopoietic stem cells may therefore result in the exclusion of a primitive stem cell population. The molecular basis for the murine SP phenotype has been attributed to the multidrug-resistance transporter ABCG2. This study aimed to investigate ABCG2 expression from a variety of human sources and investigate the relationship between ABCG2 expression, the SP phenotype, and expression of markers such as CD34 and CD133. SP cells were observed in different haemopoietic sources, but a significant increase in the number of SP cells was observed in PB following granulocyte colony-stimulating factor mobilisation. No direct correlation between the frequency of SP cells and the expression of ABCG2 was observed. SP cells were identified in both lineage-positive and lineage-negative population and ABCG2 expression was enriched in lineage-negative SP cells. Lineage-negative SP cells were devoid of CD34 expression but enriched for CD133. Subsequent analysis revealed that ABCG2 and CD133 are coexpressed. Together, these data suggest that the ABCG2 transporter is neither required nor responsible for the SP phenotpye in many human blood cells.     

Cervical perineurial cyst, a red herring (case report)

Leprous mononeuropathy may present without demonstrable maculoanesthetical patches. A case is described in whom wasting of the right hand was initially attributed to C8 T1 entrapment radiculopathy caused by cervical perineurial cysts. On the basis of the benign nature of the perineurial cysts and questionable right ulnar nerve thickening, the patient was given a trial of anti-leprosy drugs. A follow-up clinico-electrophysiological evaluation favored the diagnosis of leprotic ulnar mononeuropathy.     

A state of the art review on optimal practices to prevent,recognize, and manage complications associated with intravascular devices in the critically ill

Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.