Usually guidewires are used to lead catheters or other medical devices through the human body. For the first time, we present a technique of advancing a guidewire over another guidewire without the use of a catheter.
<b><i>Background: </i></b>Whipple's disease (WD) is rarely the cause of a malabsorption syndrome. The disease is a chronic infection of the intestinal mucosa with the bacterium <i>Tropheryma whipplei</i>, which leads to a lymphostasis with an impaired absorption of the nutrition. Due to its low incidence (1:1,000,000) and the non-specific early symptoms, the disease is often diagnosed only after many years. <b><i>Methods: </i></b>Based on a selective literature review and the clinical experience of the authors, the current knowledge of WD regarding pathogenesis, clinical presentation, diagnosis, and therapy are presented in this paper. <b><i>Results: </i></b>Recent studies suggest that a host-specific dysfunction of the intestinal macrophages is responsible for the chronic infection with <i>T. whipplei</i>. Prior to patients reporting symptoms of a malabsorption syndrome (chronic diarrhea/steatorhea, weight loss), they often suffer from non-specific symptoms (polyarthralgia, fever, fatigue) for many years. Misdiagnoses such as seronegative polyarthritis are frequent. Furthermore, neurological, cardiac, ocular, or dermatological symptoms may occur. The standard method concerning diagnosis is the detection of PAS(periodic acid-Schiff)-positive macrophages in the affected tissues. Immunohistochemical staining and PCR(polymerase chain reaction)-based genetic analysis increase the sensitivity and specificity of conventional detection methods. Endoscopically, the intestinal mucosa appears edematous with lymphangiectasias, enlarged villi, and white-yellowish ring-like structures. The German treatment recommendations include a two-week intravenous induction therapy with ceftriaxone, which is followed by a three-month oral maintenance therapy with trimethoprim/sulfamethoxazole. <b><i>Conclusion: </i></b>WD is rarely responsible for a malabsorption syndrome. However, if WD is not recognized, the disease can be lethal. New diagnostic methods and prospectively approved therapeutic concepts allow an adequate treatment of the patient. Due to the host-specific susceptibility to <i>T. whipplei</i>, a lifelong follow-up is necessary.
Background/Aims: Switching from a three-drug regimen (3DR: boosted darunavir [bDRV] and two nucleoside reverse transcriptase inhibitors [NRTIs]) to a two-drug regimen (2DR: bDRV and dolutegravir [DTG]) demonstrated non-inferiority with regard to viral suppression in people living with HIV (PLWH) in the DUALIS study. This sub-analysis focuses on changes in metabolic and renal parameters when sparing the NRTI backbone.Methods: DUALIS was a randomized, open-label, multicenter (27) phase 3-trial. Participants were virologically suppressed (HIV-RNA < 50 copies/mL) on 3DR for at least 24 weeks. Subjects were either switched to DTG 50 mg + bDRV 800 mg (with ritonavir 100 mg) (2DR) or continued their regimen consisting of two NRTIs in combination with ritonavir-bDRV (3DR) once daily. Data of metabolic and renal parameters at baseline and week 48 were compared.Results: The LDL-fraction increased by + 13.3 (-3.0 to +31.3) mg/dL on 2DRs and was stable (-14.0 to +18.0 mg/dL) on 3DRs (p < 0.0010).PLWH gained +2.0 (-0.2 to +4.0) kg and +0.2 (-1.9 to +2.1) kg in body weight on 2DRs and 3DRs, respectively 3 (p = 0.0006).The MDRD eGFR decreased by -7,8 (-17.4 to -0.3) mL/min/1.73m2 and 0.4 (-8.8 to +5.7) mL/min/1.73m2 on 2DRs and 3DRs, respectively (p = 0.0002), while serum levels of cystatin C were stable in both arms (2DR: -0.1 to +0.1 mg/L; 3DR: 0.0 to +0.1 mg/L).Conclusions: While being non-inferior in terms of viral suppression, sparing the NRTI backbone showed a non-favorable profile in metabolic or renal parameters over 48 weeks.
Hintergrund: Kolonpolypen kleiner 5 mm können den Leitlinien entsprechend mit der Zange entfernt werden. Bei Unsicherheit über die vollständige Abtragung, ist auch bei kleinen Polypen eine endoskopische Kontrolle bereits nach 2 – 6 Monaten empfohlen. Die Abtragung mittels Kaltschlingentechnik ermöglicht eine En-bloc-Resektion kleiner Polypen. Ziel der Studie war die Entwicklung und Erprobung einer Schlinge zur Kaltabtragung. Methoden: Im Rahmen einer monozentrischen, klinischen Beobachtungsstudie wurde die Anwendung der Schlinge bei kleinen Polypen (< 10 mm) bei konsekutiven Patienten geprüft. Es erfolgte keine Unterspritzung der Polypen. Primärer Endpunkt war die Rate an vollständig abgetragenen Adenomen. Komplikationen wie Blutung, Perforation, abdominelle Schmerzen wurden erfasst. Ergebnisse: Insgesamt wurden 99 Polypen bei 58 Patienten abgetragen (15 weiblich, 43 männlich; Alter 62,8 Jahre [31 – 85 Jahre]). Die durchschnittliche Polypengröße betrug 5,3 mm (2 – 10 mm). Die histologische Aufarbeitung erbrachte 88 Adenome (74 tubuläre, 4 tubulovillöse, 2 serratierte Adenome), 18 hyperplastische Polypen und ein Leiomyom. Insgesamt wurden 74 Adenome (92,5 %) vollständig reseziert. Die unvollständig resezierten Polypen waren 3 tubuläre Adenome im Sigma, ein serratiertes Adenom im Sigma sowie 2 tubuläre Adenome im rechten Hemikolon. Bezüglich der Größe betrug die Resektionsrate bei Polypen von 1 – 4 mm 90 % (27/30) und bei Polypen von 5 – 10 mm 94 % (47/50). Komplikationen traten nicht auf. Diskussion: Diese Studie zeigt, dass die Kaltschlingenabtragung kleiner Polypen eine hohe vollständige Abtragungsrate (R0) ermöglicht. Sie hilft Piece-meal-Abtragungen bei kleinen Polypen zu vermeiden.
We present a case of tacrolimus intoxication with an achalasia-like esophageal motility disorder in a long term-term renal recipient, who was admitted to hospital because of an acute on chronic kidney transplant injury and newly onset dysphagia. Esophageal manometry secured the diagnosis. Unfortunately despite recovered kidney function the clinical outcome of our index patient was fatal. He deceased in consequence of an extensive esophageal rupture. Our case demonstrates a rare but potentially serious complication of post-transplant patients on calcineurin inhibitors. Calcineurin inhibitor-induced achalasia should be considered in this population when newly onset dysphagia occurs with otherwise negative workup.
<b><i>Background:</i></b> Post-operative infection is a common complication following abdominal surgery. The two most common infections are secondary peritonitis and surgical site infections, which lead to increased perioperative morbidity, prolonged hospitalization, higher mortality rates, and increased treatment costs. In addition to surgical procedures, treatment is based on effective antibiotic therapy. Due to increasing antimicrobial resistance, the correct use of antimicrobials is becoming more complex. Many initiatives call for the implementation of an antimicrobial stewardship (AMS) programme to optimize anti-infective therapy. The review article summarizes current recommendations in anti-infective therapy of post-operative peritonitis and surgical site infections and highlights the importance of an AMS programme in abdominal surgery. <b><i>Summary:</i></b> Larger studies evaluating the benefit of AMS in abdominal surgery are lacking. However, national and international guidelines have formulated appropriate recommendations for the rational use of antibiotics in post-operative peritonitis and surgical site infections. The rate of post-operative infections can be significantly reduced by perioperative antibiotic prophylaxis. The increase in multidrug-resistant bacteria complicates anti-infective therapy for post-operative infections. Analysis of local susceptibility patterns helps choose an adequate empiric therapy. A high rate of extended-spectrum beta-lactamase-producing bacteria may necessitate the use of other reserve antibiotics in addition to carbapenems, which are approved for the treatment of complicated intra-abdominal infections. A key role for the AMS team is the subsequent de-escalation of antibiotic therapy which limits the use of unnecessary broad-spectrum antibiotics. <b><i>Key Messages:</i></b> The increase in multidrug-resistant bacteria poses challenges for abdominal surgery. Post-operative infections should be treated by an interdisciplinary team of surgeons and specialists for AMS.
Recently we reported a new technique that enables the positioning of a second guidewire following a first wire without the use of a catheter [1]. Using a wire with a double-bend tip, which forms the shape of a helix, it is possible to wrap the new wire around a first guidewire and advance it. We have already successfully demonstrated this technique in biliary interventions [1]. In the following, we present the case of a patient with a symptomatic pancreatic fluid collection, in whom we used this technique to pass a second wire into the pseudocyst to allow drainage with two double-pigtail stents.
Abstract Purpose The influence of new SARS-CoV-2 variants on the post-COVID-19 condition (PCC) remains unanswered. Therefore, we examined the prevalence and predictors of PCC-related symptoms in patients infected with the SARS-CoV-2 variants delta or omicron. Methods We compared prevalences and risk factors of acute and PCC-related symptoms three months after primary infection (3MFU) between delta- and omicron-infected patients from the Cross-Sectoral Platform of the German National Pandemic Cohort Network. Health-related quality of life (HrQoL) was determined by the EQ-5D-5L index score and trend groups were calculated to describe changes of HrQoL between different time points. Results We considered 758 patients for our analysis (delta: n = 341; omicron: n = 417). Compared with omicron patients, delta patients had a similar prevalence of PCC at the 3MFU (p = 0.354), whereby fatigue occurred most frequently (n = 256, 34%). HrQoL was comparable between the groups with the lowest EQ-5D-5L index score (0.75, 95% CI 0.73–0.78) at disease onset. While most patients (69%, n = 348) never showed a declined HrQoL, it deteriorated substantially in 37 patients (7%) from the acute phase to the 3MFU of which 27 were infected with omicron. Conclusion With quality-controlled data from a multicenter cohort, we showed that PCC is an equally common challenge for patients infected with the SARS-CoV-2 variants delta and omicron at least for the German population. Developing the EQ-5D-5L index score trend groups showed that over two thirds of patients did not experience any restrictions in their HrQoL due to or after the SARS-CoV-2 infection at the 3MFU. Clinical Trail registration The cohort is registered at ClinicalTrials.gov since February 24, 2021 (Identifier: NCT04768998).
