Restarting LDLT During COVID-19: Early Results After Restructuring

IntroductionLiving-donor liver transplantation (LDLT) has been mostly suspended and deceased-donor living transplantation activity has been considerably reduced because of coronavirus disease 2019 (COVID-19). We modified our protocols and procedures in line with COVID-19 guidelines. Since the restructuring, we have performed 20 LDLTs. Our study reports the outcomes of these cases and demonstrates the feasibility of LDLT during this pandemic.Materials and MethodsThe changes were influenced by experiences and communications from across the globe. A month-long self-imposed moratorium was spent in restructuring the program and implementing new protocols. Twenty LDLTs were performed between April 18 and September 15 using the new protocols. Our experience includes 2 simultaneous liver-kidney transplants, 1 ABO-incompatible LDLT, and 1 pediatric case (age 11 months).ResultsNineteen patients recovered and 1 patient died. We maintained our postoperative immunosuppression protocol without many changes. Major complications were observed in 30% of recipients but none of the donors. One recipient was infected with COVID-19 during the postoperative period. A donor-recipient couple contracted COVID-19 after discharge from the hospital. All patients recovered from COVID-19 and liver enzymes were unaffected.ConclusionThis study represents a microcosm of experience in LDLT during the COVID-19 era. Outcomes of LDLT are not affected by COVID-19 per se, provided that we make necessary changes.     

Cardiac troponin I, cardiac troponin T and creatine kinase MB concentrations in umbilical cord blood of healthy term neonates

AIMS: To measure and compare cardiac troponin I, cardiac troponin T and creatine kinase MB concentrations in the umbilical cord blood of healthy term infants and to investigate the relationship between maternal and neonatal troponin values at birth. METHODS: Troponin I, troponin T and creatine kinase MB concentrations were measured from the umbilical cord samples of 85 healthy term neonates and in the blood samples of their respective mothers at birth. RESULTS: Median (interquartile range) umbilical cord concentrations were 0 microg/L (0-0) for troponin I, 0 microg/L (0-0.019) for troponin T and 4.90 microg/L (3.90-6.61) for creatine kinase MB. Troponin I and T concentrations were higher than the detection limit for the assay in 2 (2.3%) and 41 (48.2%) neonates, respectively. Two mothers (2.3%) had cTnT levels above the detection limit; none of them had increased levels of cTnI. CONCLUSION: Probably owing to differences in expression and assay detection limits, cord blood troponin T concentrations are frequently over the detection limit at birth, while troponin I is mostly undetectable and comparable with that in healthy pregnant women. These cardiac regulatory proteins are of neonatal origin and are not influenced by maternal levels.     

Endovascular carotid reconstruction in palliative head and neck cancer patients with threatened carotid blowout presents a beneficial supportive care measure

ABSTRACT Carotid blowout is a devastating complication in patients with head and neck malignancy. The traditional surgical treatment for carotid blowout is often technically difficult and is associated with an unacceptably high morbidity and mortality. Recently, endovascular therapy has been proposed for head and neck surgical patients. Preliminary reports showed a better outcome with less morbidity and mortality compared to the previous treatment modalities. The use of such techniques in cases of impending or acute carotid blowout syndrome has been previously described to be beneficial for palliative head and neck cancer patients as well. We introduce a case of a head and neck cancer patient receiving palliative care, presenting with threatened carotid blowout, who was managed with endovascular placement of a covered stent under elective conditions in order to prevent an inevitable carotid rupture. In the present case endovascular carotid stenting allowed preservation of the vessel, prevented the dramatic situation of carotid rupture, and facilitated a rapid hospital discharge without any neurologic or stenting sequelae.     

R factor-mediated and chromosomal resistance to ampicillin in Escherichia coli

Sixty-four ampicillin-resistant strains of Escherichia coli were studied. Six characters were examined: (i) resistance to ampicillin, cephalothin, and carbenicillin, (ii) synergy between ampicillin and cloxacillin, (iii) level of beta-lactamase activity after osmotic shock, (iv) transferability of ampicillin resistance, (v) immunological characterization of the enzyme, and (vi) determination of substrate profiles. One class of strains was found in which synthesis of beta-lactamase is inferred to be plasmid mediated; these strains are highly resistant to ampicillin and carbenicillin, sensitive to cephalothin, do not show synergism between ampicillin and cloxacillin, and reveal a high enzymatic activity after osmotic shock. A second class is formed by strains for which beta-lactamase synthesis is inferred to be chromosomal; these strains present a low resistance level to ampicillin, are sensitive to carbenicillin and resistant to cephalothin, show a synergism between ampicillin and cloxacillin, and reveal a very low enzymatic activity after osmotic shock. These characters may be used to differentiate periplasmic and cell-bound beta-lactamases.     

Radiation Exposure in Nonvascular Fluoroscopy-Guided Interventional Procedures

Purpose

To investigate the radiation exposure in non-vascular fluoroscopy guided interventions and to search strategies for dose reduction.

Materials and Methods

Dose area product (DAP) of 638 consecutive non-vascular interventional procedures of one year were analyzed with respect to different types of interventions; gastrointestinal tract, biliary interventions, embolizations of tumors and hemorrhage. Data was analyzed with special focus on the fluoroscopy doses and frame doses. The third quartiles (Q3) of fluoroscopy dose values were defined in order to set a reference value for our in-hospital practice.

Results

Mean fluoroscopy times of gastrostomy, jejunostomy, right and left sided percutaneous biliary drainage, chemoembolization of the liver and embolization due to various hemorrhages were 5.9, 8.6, 13.5, 16.6, 17.4 and 25.2 min, respectively. The respective Q3 total DAP were 52.9, 73.3, 155.1, 308.4, 428.6 and 529.3 Gy*cm². Overall, around 66% of the total DAP originated from the radiographic frames with only 34% of the total DAP applied by fluoroscopy (P < 0.001). The investigators experience had no significant impact on the total DAP applied, most likely since there was no stratification to intervention-complexity.

Conclusion

To establish Diagnostic Reference Levels (DRLs), there is a need to establish a registry of radiation dose data for the most commonly performed procedures. Documentation of interventional procedures by fluoroscopy “grabbing” has the potential to considerably reduce radiation dose applied and should be used instead of radiographic frames whenever possible.     

Kinetic properties of two plasmid-mediated beta-lactamases from Klebsiella pneumoniae with strong activity against third-generation cephalosporins

We determined the kinetic constants for two plasmid-mediated beta-lactamases with strong activity against third-generation cephalosporins: CTX-1 and SHV-2. The enzymes had many similar properties: their synthesis was constitutive and they were significantly active against penicillins as well as cephalosporins. The two enzymes thus differed considerably from the chromosomal cephalosporinases, but bore some resemblance to the commonly-encountered plasmid-coded penicillinases, such as TEM beta-lactamases. Moreover, like the TEM enzymes, the plasmid-mediated CTX-1 and SHV-2 enzymes were highly sensitive to the action of the inhibitors clavulanic acid and sulbactam. These inhibitors protected cefotaxime from hydrolysis by these enzymes. Both CTX-1 and SHV-2 lacked activity against the cephamycins, cefoxitin, latamoxef (moxalactam) and cefotetan. The CTX-1 and SHV-2 enzymes had a low activity against oxacillin and were not sensitive to chloride ions. Thus, they were not related to the OXA type beta-lactamases. For the third-generation cephalosporins the rates of hydrolysis were high and thus bore no relation with those observed for the other presently-known beta-lactamases, with perhaps the exceptions of those produced by K. oxytoca. Imipenem was very resistant to the action of these CTX-1 and SHV-2 beta-lactamases.     

Krurale und pedale Bypasschirurgie bei kritischer Ischämie und nicht heilenden Fußläsionen

Zusammenfassung Die Ischämie ist der häufigste Grund für nicht heilende Läsionen an den Füßen. Mit der weltweiten Zunahme vaskulärer Erkrankungen und insbesondere des diabetischen Fußsyndroms steigt auch die Zahl der Patienten, die durch eine Revaskularisation geheilt werden können, momentan aber überwiegend (25.000/Jahr in Deutschland) amputiert werden. In den letzten Jahrzehnten sind in der Gefäßchirurgie subtile Methoden entwickelt worden, die auch eine Revaskularisation und Bypassoperationen bei Patienten mit einem distalen Verschlusstyp, der immer häufiger und gerade beim Diabetiker angetroffenen wird, zulassen. Eine besondere Rolle spielt hier der Venenbypass aus V. saphena magna oder alternativen Venen. Der Prothesenbypass, aus Nabelschnurvene oder Kunststoff, kann nur mit adjunktiven Techniken zur Optimierung der distalen Anastomose eine längerfristige Funktion erzielen. Venen- und Prothesenbypass führen in über 90% sofort und in etwa 75% auch längerfristig zur raschen Abheilung von Wunden und zur Wiedererlangung der Gebrauchsfähigkeit der Extremität. Eine solch effektive Therapiemaßnahme sollte bei chronischen Wunden unbedingt in Betracht gezogen werden. Die Bypassfunktion auf Unterschenkel- und Fußarterien ist mit einem durchschnittlichen Extremitätenerhalt von 75% nach 3 Jahren hervorragend und sollte keinem Patienten vorenthalten werden.