Intravenous Hyperalimentation Research Articles

Investigation of in-line filter replacement intervals for infusion

In-line filters in peripheral and central venous catheters are used to mechanically remove bacterial cells. A recent study indicated the extension of the use of infusion sets to seven days. There is no evidence regarding replacement intervals for in-line filters. We tested in-line filters that were continuously used for seven days for ability to remove bacteria as well as flow rate. Three different in-line filters were attached to an ELNEOPA-NF No.2® premixed infusion bag of intravenous hyperalimentation, into which Staphylococcus epidermidis ATCC12228 or Escherichia coli ATCC25922 was inoculated. These experiments were compared with a control infusion. The infusion was dropped at a flow rate of 40 mL/h and replaced at 24-h intervals for seven days. Samples were collected 24 h after drop initiation. S. epidermidis was not detected in droplets between Days 1 and 6, while in-line filters 1 and 2 showed droplets containing 6-10 CFU/mL on Day 7. E. coli was not detected in any of the filters. Flow rates below 40 mL/h were observed on Day 7 in in-line filter 3 in studies of S. epidermidis, and on Days 4 and 3 in in-line filters 2 and 3, respectively, in studies of E. coli. Our study revealed differences in bacterial removal and flow rate under high inoculation among each of three tested in-line filters. We suggest the continuous use of in-line filters for a maximum of six days, while reductions in flow rate after 48 h of continuous use should be carefully noted.

Catheter-related bloodstream infection in patients With severe anorexia nervosa.

Anorexia nervosa (AN) may be treated with intravenous hyperalimentation (IVH) that may be associated with catheter-related bloodstream infection (CRBSI). Retrospective chart review was conducted to compare those who developed CRBSI were compared with those who did not. Of 34 patients, 17 episodes of AN treated with IVH were identified, of which five resulted in CRBSI. The average body mass index at admission was low at 12.2. Patients who needed physical restraint during IVH had a higher (albeit statistically nonsignificant) risk. Also, those with purging had numerically lower risk. CRBSI complicated IVH in 29.4% instances of severe life-threatening AN in our sample. Whether physical restraints and no purging constitute a risk factor of CRBSI needs to be further investigated.

Screening rates and prevalence of osteoporosis in a real-world, Australian systemic sclerosis cohort.

Despite reports of decreased bone mineral density in patients with systemic sclerosis (SSc) in international cohorts, the prevalence of osteoporosis in Australian SSc patients remains unknown. We report rates of dual-energy X-ray absorptiometry (DXA) scanning in an SSc cohort at a tertiary hospital specialized outpatient clinic and the prevalence and associations of osteoporosis in screened patients. We performed retrospective chart review to determine if patients underwent DXA scanning between 2007 and 2018 and extracted lumbar spine and femoral neck T-scores, fracture history, and osteoporosis therapy. Of 244 patients, 104 (42.6%) underwent DXA scanning and among patients in whom T-scores were available (n = 91), 30 (33.0%) had osteoporosis and 48 (52.7%) had osteopenia. Screened patients were more likely to have longer disease duration (19.9 vs 15.2 years, P = 0.002), calcinosis (50.5% vs 36.4%, P = 0.028), myositis (12.6% vs 0.7%, P < 0.001), synovitis (42.7% vs 28.6%, P = 0.022), ever used prednisolone (76.7% vs 47.1%, P < 0.001) or fractures (23.0% vs 0.0%, P < 0.001). Patients with osteoporosis more commonly had a history of nasogastric feeding, percutaneous endoscopic gastrostomy feeding or intravenous total parenteral nutrition (6.9% vs 0.0%, P = 0.038) and, unexpectedly, less commonly ever used prednisolone (58.6% vs 85.2%, P = 0.005) compared with patients with osteopenia or normal bone density. We identified high rates of osteoporosis among screened Australian SSc patients. Further assessment in larger, prospective studies is needed to establish guidelines for formal osteoporosis screening in SSc patients.

Quantitative profiling of inflammatory and pro-resolving lipid mediators in human adolescents and mouse plasma using UHPLC-MS/MS.

Lipid mediators are bioactive lipids which help regulate inflammation. We aimed to develop an ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method to quantify 58 pro-inflammatory and pro-resolving lipid mediators in plasma, determine preliminary reference ranges for adolescents, and investigate how total parenteral nutrition (TPN) containing omega-3 polyunsaturated fatty acid (n-3 PUFA) or n-6 PUFA based lipid emulsions influence lipid mediator concentrations in plasma. Lipid mediators were extracted from plasma using SPE and measured using UHPLC-MS/MS. EDTA plasma was collected from healthy adolescents between 13 and 17 years of age to determine preliminary reference ranges and from mice given intravenous TPN for seven days containing either an n-3 PUFA or n-6 PUFA based lipid emulsion. We successfully quantified 43 lipid mediators in human plasma with good precision and recovery including several leukotrienes, prostaglandins, resolvins, protectins, maresins, and lipoxins. We found that the addition of methanol to human plasma after blood separation reduces post blood draw increases in 12-hydroxyeicosatetraenoic acid (12-HETE), 12-hydroxyeicosapentaenoic acid (12-HEPE), 12S-hydroxyeicosatrienoic acid (12S-HETrE), 14-hydroxydocosahexaenoic acid (14-HDHA) and thromboxane B2 (TXB2). Compared to the n-6 PUFA based TPN, the n-3 PUFA based TPN increased specialized pro-resolving mediators such as maresin 1 (MaR1), MaR2, protectin D1 (PD1), PDX, and resolvin D5 (RvD5), and decreased inflammatory lipid mediators such as leukotriene B4 (LTB4) and prostaglandin D2 (PGD2). Our method provides an accurate and sensitive quantification of 58 lipid mediators from plasma samples, which we used to establish a preliminary reference range for lipid mediators in plasma samples of adolescents; and to show that n-3 PUFA, compared to n-6 PUFA rich TPN, leads to a less inflammatory lipid mediator profile in mice.

Clinical Impact of Oral Intake in Second-line or Third-line Chemotherapy for 589 Patients With Advanced Gastric Cancer: A Retrospective Cohort Study.

Insufficient oral intake in advanced gastric cancer (AGC) limits the use of several drugs. We aimed to determine the oral intake status of patients with AGC during later-line chemotherapy. We retrospectively evaluated data of patients with AGC who experienced disease progression during first-line chemotherapy administered from January 2012 to December 2018 in a single institution. We defined "insufficient oral intake" as requiring daily intravenous fluids or hyperalimentation. Multivariate logistic regression was performed to identify oral intake-related factors. Among 589 included patients, at disease progression during first-line, second-line, and third-line chemotherapy, 78.3% (461), 53.3% (314), and 30.4% (179) of patients, respectively, exhibited sufficient oral intake. Fourth-line chemotherapy was initiated for 22.2% (131) of patients, with 20.0% (118) exhibiting sufficient oral intake. During second-line and third-line chemotherapy, 11/67 (16%) and 2/39 (5%) patients, respectively, exhibited improvements in oral intake; 85/428 (19.9%) and 70/259 (27.0%), respectively, exhibited deteriorations in oral intake. Factors correlated to deterioration in oral intake during second-line chemotherapy were poor Eastern Cooperative Oncology Group Performance Status (odds ratio, 4.32; P<0.001), moderate or severe ascites (1.96; P=0.045), peritoneal metastasis (2.12; P=0.029), prior palliative surgery (3.41; P=0.003), and high neutrophil-to-lymphocyte ratio (3.09; P<0.001); those correlated to deterioration in oral intake during third-line chemotherapy were poorly differentiated pathology (2.52; P=0.025) and high neutrophil-to-lymphocyte ratio (2.65; P=0.006). As later-line chemotherapy is ineffective in improving oral intake in patients with AGC, careful adaptation of regimens is required for patients at risk for impaired oral intake.

Ward‐level nurse turnover and related workplace factors in long‐term care hospitals: A cross‐sectional survey

To explore the association between the ward-level nurse turnover rate and the ward's organisational, patient and nurse characteristics in long-term care (LTC) hospitals. Nurse turnover adversely impacts not only LTC hospitals through higher recruitment and replacement costs but also resident health outcomes. This study employed across-sectional design with secondary analyses. Participants were 199 ward managers and 2,508 nurses in LTC hospitals across Japan. Data were collected between September and November 2015. The wards with higher nurse turnover were significantly associated with a non-12-hr work shift, higher rate of patients with intravenous hyperalimentation (IVH), lower average of nurse emotional exhaustion, lower average of nurse-perceived quality of the care process and lower rate of employment stability as the reason for choosing the workplace. Actual ward-level nurse turnover can be influenced by factors related to the organisation (e.g. shift style and employment stability), patient (e.g. patients with IVH) and nurse attributions (e.g. burnout, perceived care quality). To minimize nurse turnover in LTC hospitals, multifactorial ward-level interventions would be possible, such as adjusting for shift work, attending to medical procedures or improving nurses' emotional exhaustion and perceptions regarding care quality.

An analysis of oral microbial flora by T-RFLP in patients undergoing hematopoietic stem cell transplantation

Even though the hematopoietic stem cell transplantation (HSCT) procedure has been improved, oral mucositis (OM) is still a severe complication of the conditioning regimen. We investigated the association between OM severity and the alteration of oral bacterial flora using 16S rRNA gene-based terminal restriction fragment length polymorphism (T-RFLP) analysis in 19 consecutive patients undergoing HSCT. Oral samples were collected at pre-transplantation, at the peak of mucositis and post-engraftment. T-RFLP profiles for each timepoint were constructed into an X-Y matrix, and the distances between timepoints were calculated. Patients with severe and moderate OM had larger changes in their oral bacterial flora from before HSCT to peak of mucositis than controls (p = 0.031 and 0.016, respectively). Moreover, severe mucositis was significantly associated with an extended period of fever until engraftment, high maximum C-reactive protein levels, and prolonged periods of opioid treatment and intravenous hyper-alimentation. These findings suggest that mucositis severity is associated with the magnitude of change in the oral bacterial flora. This novel finding may help advance strategies for the prevention or treatment of OM after HSCT.

Clinical impact of oral intake on second-line treatment of advanced gastric cancer.

e16560 Background: Trifluridine/tipiracil, an oral drug, was approved in Japan for patients (pts) with advanced gastric cancer (AGC). Insufficient oral intake (INSUF) is one of the most common complications. We evaluated the clinical characteristics and impact of oral intake during 2nd line chemotherapy (CT). Methods: We retrospectively evaluated AGC pts receiving 2nd line CT from January 2012 to December 2018 at a single institution. We defined “INSUF” as a requirement for daily intravenous fluids or hyperalimentation and “improvement of oral intake (IMP)” as no such requirement for &gt; 1 week. Exacerbation (EXA) was defined as a change from “sufficient oral intake (SUF)” to INSUF. Results: We enrolled 495 pts, of which 67 (13%) and 428 (87%) pts had INSUF and SUF at the start of 2nd line CT, respectively. Patient characteristics are summarized in the Table. There was no difference in the cytotoxic drugs of 2nd line CT. The causes of INSUF were peritoneal metastases (79%), cachexia (15%), and primary complications (3%). The objective response rates of INSUF and SUF pts were 9% and 26%, respectively. INSUF pts had poorer progression-free survival (PFS) (1.7 vs. 3.7 months [M]; adjusted HR [aHR], 1.51; p &lt; 0.001) and overall survival (3.2 vs. 10.1 M; aHR, 2.01; p &lt; 0.001) than SUF pts. At the end of 2nd line CT, 147 (32%) and 314 (68%) pts had INSUF and SUF, respectively. In SUF pts, the factors correlated with EXA were poor ECOG PS (odds ratio [OR], 5.26; p &lt; 0.001), massive or moderate ascites (OR, 2.04; p = 0.031), palliative operation history (OR, 2.90; p = 0.007), and ramucirumab use (OR, 0.50; p = 0.034). Median PFS was shorter after CT in pts with EXA than in those without (1.7 vs. 4.2 M; aHR, 2.05; p &lt; 0.001). Among INSUF pts, 11 pts (16%) achieved IMP; the rate of IMP did not differ according to regimen. Median PFS was shorter in pts without IMP than in pts with IMP (1.1 vs. 3.3 M; aHR, 4.97; p = 0.001). Subsequent CT was administered to 29% and 71% of INSUF and SUF pts, respectively. Conclusions: INSUF at the start of 2nd line CT was a poor prognostic factor. For appropriate use of oral drugs, CT should be changed in SUF pts with factors associated with EXA. [Table: see text]

Successful Allogeneic Stem Cell Transplantation in Nuclear Factor-Kappa B Essential Modulator Deficiency Syndrome After Treosulfan-Based Conditioning: A Case Report

BackgroundX-linked EDA-ID1 (ectodermal dysplasia, anhidrotic, with immunodeficiency 1, Online Mendelian Inheritance in Man [OMIM] 300291), or NEMO (nuclear factor kappa B essential modulator) deficiency syndrome, is caused by mutations in the IKBKG/NEMO gene. We report the case of a boy with EDA-ID1 who underwent allogeneic stem cell transplantation. MethodsIn early infancy, the patient developed an atypical, severe, initial manifestation resembling Omenn syndrome with infections, and he underwent allogeneic stem cell transplantation from an unrelated 9 of 10 HLA matched donor with a mismatch in the DQB1 allele after conditioning with treosulfan, fludarabine, thiotepa, and antithymocyte globulin (Grafalon). The post-transplant period was complicated by cytomegalovirus replication and mild, grade 2 graft vs host disease. Because of NEMO deficiency syndrome–associated enteropathy and continuous weight loss, parenteral nutrition was started and the patient was fed an elemental formula and a gluten-free diet. Over a period of 3 years, the patient had 7 incidents of blood stream infections caused by Staphylococci or gut-derived Gram-negative flora, with 1 incident of septic shock caused by Escherichia coli. The blood stream infection stopped after gastrointestinal tract decontamination was done once per month for 7-day courses alternately with rifaximin, vancomycin, and gentamicin sulfate. ConclusionsPatients with NEMO deficiency syndrome require very complex, multidisciplinary care, and immunodeficiency correction can only be observed as one of the critical points in patient care. Developmental problems, enteropathy with the need for intravenous hyperalimentation, and specific interventions for other clinical manifestations of multifaceted syndrome are needed for proper care.

A CASE OF ILEAL CONDUIT-ENTERIC FISTULA AFTER ROBOTIC INTRACORPOREAL ILEAL CONDUIT URINARY DIVERSION

The complications of ileal conduit urinary diversion were reported to be urinary tract infections, bowel obstruction, and delayed wound healing, but ileal conduit-enteric fistula is rare. We report a case of ileal conduit-enteric fistula after robotic intracorporeal ileal conduit urinary diversion. An 81-year-old man with muscle-invasive bladder cancer underwent robot-assisted radical cystectomy and intracorporeal ileal conduit urinary diversion. Twenty-two days after the surgery, we identified the presence of fecaluria. Loopography revealed an ileal conduit-enteric fistula. He underwent conservative treatment with fasting and intravenous hyperalimentation. Loopography was performed 48 days after the surgery. However, the fistula remained. Therefore, fistula closure surgery was performed 51 days after the surgery. Here we review the characteristics of 4 ileal conduit-enteric fistula cases reported in Japan.

Decreasing Use of Percutaneous Endoscopic Gastrostomy Tube Feeding in Japan.

To identify trends in percutaneous endoscopic gastrostomy (PEG) tube placement and intravenous hyperalimentation (IVH) in nonhospital settings (as a potential alternative to tube feeding for nutrition) and to summarize published reports concerning the decision-making process for PEG placement. National survey and systematic review. Japan. All Japanese people. Data on numbers of individuals with a PEG tube and IVH were obtained from the website of the Japanese Ministry of Health, Labour, and Welfare and published reports concerning the decision-making process for PEG placement in Japan were summarized. The number of PEG tube placements peaked in 2007 and has been decreasing since Japan experienced the Great East Japan Earthquake in 2011. A further decline was seen in 2015 after the Japanese Ministry of Health, Labour and Welfare revised the fee schedule in 2014. More than half of individuals who had tubes were aged 80 and older during the years observed. In contrast, the number of individuals receiving IVH was lowest in the same year as PEG tube placement peaked and has been increasing ever since. Four studies reported that the decision-making process included consideration of not only the underlying disease, but also the individual's age and social barriers and the physician's personal philosophy. The number of PEG tube placements has been decreasing since its peak in 2007, and the number of individuals receiving IVH has been increasing. Many factors influence the decision-making process for PEG tube placement. Physicians in Japan may be realizing that there is little evidence to support the use of tube feeding in frail elderly adults.

Trends in the neurodevelopmental outcomes among preterm infants from 2003\u20132012: a retrospective cohort study in Japan

ObjectivesTo determine the trends in mortality and the prevalence of abnormal neurodevelopmental outcomes among preterm Japanese infants.Study designA retrospective multicenter cohort of 30,793 preterm infants born at a gestational age ≤32 weeks, between 2003 and 2012, in the Neonatal Research Network, Japan, was evaluated in the primary analysis. Finally, 13,661 infants were followed-up until 3 years of age and evaluated for neurodevelopmental outcomes, including cerebral palsy (CP), home oxygen therapy (HOT) use, and visual, hearing, and cognitive impairments. Multivariable logistic regression analysis was performed to determine the risk-adjusted trends in mortality and long-term neurodevelopmental outcomes.ResultsThe trends in overall mortality (adjusted odds ratio, (AOR): 0.92; 95% confidence interval, (CI): 0.89–0.94), the prevalence of CP (AOR: 0.95, 95% CI: 0.92–0.98), HOT use (AOR: 0.84, 95% CI: 0.75–0.93), and visual (AOR: 0.84, 95% CI: 0.81–0.87) and hearing impairments (AOR: 0.78, 95% CI: 0.63–0.97) showed a significant downward trend, while cognitive impairment showed no significant changes (AOR: 1.02, 95% CI: 0.99–1.05). Intravenous hyperalimentation was significantly correlated with visual impairment (AOR 0.74, 95% CI 0.59–0.91). Early establishment of enteral feeding was associated with improved long-term outcomes.ConclusionsMortality was improved, and this did not lead to increased risks for abnormal neurodevelopmental outcomes. Nutritional support might improve long-term neurodevelopmental outcomes.

中心静脈栄養とともに包括的,多面的医療を行い,軽快した20年間の病歴を有する神経性食欲不振症の1例

中心静脈栄養とともに包括的,多面的医療を行い,軽快した20年間の病歴を有する神経性食欲不振症の1例

Manometric evidence of earlier recovery of fasting gastric motility after antecolic duodenojejunostomy than after retrocolic duodenojejunostomy following PPPD.

Gastric stasis is a unique complication of pylorus-preserving pancreatoduodenectomy (PPPD). Although some studies reported less prevalence of gastric stasis after antecolic duodenojejunostomy, there have been no reports on detailed comparison of gastric motility after antecolic vs. retrocolic duodenojejunostomy after PPPD. Thirty-six patients underwent PPPD with the modified Child reconstruction. Retrocolic duodenojejunostomy was utilized in initial 13 patients (retrocolic group). For comparison, antecolic duodenojejunostomy was employed in subsequent 23 patients (antecolic group). A manometric tube assembly was inserted into the gastric antrum and jejunum during PPPD. Gastrointestinal motility was recorded for 3 hours a day, starting on 6 to 14 days after surgery and repeated at a weekly interval until the first appearance of phase 3 gastric motility. Various clinical parameters were also assessed. Recovery of gastric phase 3 was identified in 19 of 36 patients. Recovery of phase 3 was faster in antecolic group than in retrocolic group (p<0.01). The amount of the gastric juice output during 14 postoperative days was larger in retrocolic group than in antecolic group (p<0.01). Resumption of water intake and food intake was earlier and the length of intravenous hyperalimentation and hospital stay was shorter in antecolic group than in retrocolic group (p<0.05). Antecolic duodenojejunostomy contributes to early recovery of gastric phase 3 motility in patients after PPPD, leading to prevention of early gastric stasis.

End-of-Life Medical Treatments in the Last Two Weeks of Life in Palliative Care Units in Japan, 2005-2006: A Nationwide Retrospective Cohort Survey.

Comprehensive information on end-of-life care in specialized palliative care settings is needed to assess the quality of care. This study aimed to investigate medical treatments in the last two weeks of life in a national sample of palliative care units in Japan. Retrospective cohort study. Medical charts of 2802 consecutive cancer patients who died in 37 palliative care units were reviewed. Drug usage and treatments during the last two weeks of life were collected. A mixed-effect model was used to estimate the variations in care between institutions. Opioid administration increased from 68% (two weeks before death) to 80% (last 48 hours); during the same period, nonsteroidal anti-inflammatory drugs and acetaminophen administration decreased from 59% to 45%, and corticosteroid administration decreased from 62% to 51%. As death neared, parenteral opioid administration increased (41%-74%). Morphine use increased (45%-70%), fentanyl use remained about the same (47%-40%), and oxycodone use decreased (18%-5%). Two thirds of patients received artificial hydration; doses >1000 mL/day (15%) and intravenous hyperalimentation (7%) were relatively rare during the last 48 hours. Variations in end-of-life medical treatments increased between palliative care units as death neared, especially anticholinergic, artificial hydration, oxygen inhalation, and palliative sedation use. These findings regarding the general course of palliative treatments for dying cancer patients are useful for clinical audits in general wards, by comparing end-of-life care. Variations in some end-of-life medical treatments between institutions increased as death neared, even in palliative care settings.

たこつぼ型心筋症とrefeeding syndromeを併発し，2度の心停止を来した神経性食思不振症の1例(A case of two episodes of cardiopulmonary arrest caused by anorexia nervosa complicated with Takotsubo cardiomyopathy and refeeding syndrome)

要旨症例は22歳の女性。18歳頃から過食，嘔吐，極端なカロリー制限を繰り返していた。2か月前より1日300kcal以下にカロリーを制限し，意識障害を来して近医を救急受診した。低血糖を指摘され，ブドウ糖を投与された。翌日再度意識障害を来して同院を受診し，受診後心室細動に至ったが，心拍再開後当院に転院となった。来院時BMI 13.2kg/m2と著しく低下しており，心エコー検査上びまん性の壁運動低下を認めた。心電図上QTcは0.51秒と延長しており，その原因は心停止の影響もしくは神経性食思不振症（anorexia nervosa: AN）に伴うものと考えられた。来院同日，ICU入室後の心エコー検査では心基部の過収縮および心尖部の無収縮を認めた。第2病日再度心停止（pulseless electrical activity: PEA）となり，心肺蘇生法により心拍再開したが，血糖値は13mg/dLと低値であった。心血管造影上冠動脈に有意な狭窄はなかったが，左室造影にて心基部の過収縮と心尖部の無収縮を認め，たこつぼ型心筋症と診断した。その後，低血糖を防ぐために徐々に投与カロリーを増量したが，第4病日より低リン血症，汎血球減少を認め，refeeding syndrome（RS）と考えられる病態となったものの治療経過は良好で，第44病日当院精神科に転科した。ANにたこつぼ型心筋症が併発する要因として，低血糖が指摘されており，本症例も低血糖が誘因であったと思われる。また低血糖を来したことにより，投与カロリーを増量せざるを得ず，リンの投与が遅れたことがRSを生じた原因として考えられた。本症例の2回の心停止の原因は経過や検査所見より，QT延長やたこつぼ型心筋症などが関連した可能性が考えられた。ANに低血糖が生じた際には，たこつぼ型心筋症による循環不全および糖負荷によるRSの発症に十分に留意する必要がある。

A Case of Intestinal Obstruction in Pregnancy Diagnosed by MRI and Treated by Intravenous Hyperalimentation.

Intestinal obstruction in pregnancy is rare and is mainly caused by prior pelvic surgery. We herein report a case of intestinal obstruction in a pregnant female with a history of laparoscopic myomectomy, who presented with hypogastric pain, abdominal distension, and vomiting at 26 weeks of gestation. A simple intestinal obstruction was diagnosed by MRI. Conservative treatments, including intravenous hyperalimentation and the placement of an ileus tube, were provided and her abdominal symptoms improved for 14 days. After restarting oral intake, she had no abdominal symptoms. She gave birth to a 2,146 g female infant by caesarean section at 37 weeks and 1 day of gestation. Although an area of cicatrization, which was thought to have been the starting point of the occlusion that caused the intestinal obstruction, was found, the excision of the small intestine was not necessary. Her postoperative course was uneventful. Intestinal obstruction requires a prompt diagnosis and aggressive intervention may be necessary to minimize the morbidity and mortality associated with this rare complication of pregnancy. MRI can be safely used during pregnancy to diagnose intestinal obstruction and intravenous hyperalimentation may improve the maternal and fetal prognoses.

Myelopathy mimicking subacute combined degeneration in a Down syndrome patient with methotrexate treatment for B lymphoblastic leukemia: Report of an autopsy case

We report clinicopathological features of a 23-year-old woman with Down syndrome (DS) presenting with subacute myelopathy treated with chemotherapy, including intravenous and intrathecal administration of methotrexate (MTX), and with allogenic bone-marrow transplantation for B lymphoblastic leukemia. Autopsy revealed severe demyelinating vacuolar myelopathy in the posterior and lateral columns of the spinal cord, associated with macrophage infiltration, marked axonal loss and some swollen axons. Pathological changes of posterior and lateral columns were observed from the medulla oblongata to lumbar cord. Proximal anterior and posterior roots were preserved. Cerebral white matter was relatively well preserved. There were no vascular lesions or meningeal dissemination of leukemia. Longitudinal extension of cord lesions was extensive, unlike typical cases of subacute combined degeneration (SACD), but distribution of lesions and histological findings were similar to that of SACD. DS patients show heightened sensitivity to MTX because of their genetic background. Risk factors for toxic myelopathy of DS are discussed, including delayed clearance of MTX despite normal renal function, alterations in MTX polyglutamation and enhanced folic acid depletion due to gene dosage effects of chromosome 21. Alteration of folate metabolism and/or vitamin B12 levels through intravenous or intrathecal administration of MTX might exist, although vitamin B12 and other essential nutrients were managed using intravenous hyperalimentation. To the best of our knowledge, this is the first report of an autopsy case that shows myelopathy mimicking SACD in a DS patient accompanied by B lymphoblastic leukemia. The case suggests a pathophysiological mechanism of MTX-related myelopathy in DS patients with B lymphoblastic leukemia mimicking SACD.

Graft-versus-Host Disease after Living-Unrelated Kidney Transplantation.

Graft-versus-host disease (GVHD) is a rare complication after solid organ transplantation and consists of a reaction of donor derived immune cells directed against host tissues. The vast majority of cases reported in the literature involve liver, small intestine and pancreas transplantation. We report a case of GVHD in a 48-year-old man after living-unrelated kidney transplantation at another center. Six months postoperatively he developed a skin rash, anorexia, and diarrhea that resulted in malnutrition and a 90 pound weight loss. At this point he was transferred to our center with a BMI of 16 and severe cachexia. Intravenous hyperalimentation was initiated and an extensive work-up for an infectious etiology was performed and was negative. An esophagogastroduodenoscopy was performed and revealed nodularity of the gastric mucosa, atrophy, and edema in the first and second portion of his duodenum. Biopsy findings were consistent with GVHD. Aggressive immunosuppressive therapy was instituted with a good response. The anorexia and diarrhea resolved, and he was discharged on hospital day 20. Three months later, there had been no recurrence of the diarrhea, the patient had gained an additional 40 pounds, BMI of 25, and a repeat upper endoscopy revealed complete resolution of the initial endoscopic abnormalities.

The First Case of Septicemia Caused by Imipenem-Susceptible, Meropenem-Resistant Klebsiella pneumoniae

The First Case of Septicemia Caused by Imipenem-Susceptible, Meropenem-Resistant <i>Klebsiella pneumoniae</i>