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Purpose Infective endocarditis (IE) is a rare but potentially fatal complication following heart transplantation (HTx). There is a lack of literature regarding the patterns and clinical course of IE development following HTx. We sought to pool the existing data in regards to defining characteristics, management options, and outcomes of IE following HTx. Methods An electronic search of Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Ovid Medline, and the Scopus databases were performed to identify all articles in the English literature that report IE following HTx in adult patients. Patient-level data were extracted and analyzed. Results Systematic search yielded 57 patients from 32 articles. Median patient age was 52 [IQR 43, 59] and 75% of patients (43/57) were male. Median time to IE presentation post-HTx was 8.4 [IQR 3.0, 35.8] months. IE of the mitral valve was observed in 36.8% (21/57) of patients, followed by mural IE in 24.6% (14/57), and tricuspid valve IE in 21.1% (12/57). The most common organisms were Staphylococcus aureus in 26.3% (15/57), Aspergillus fumigatus in 19.3% (11/57), Enterococcus faecalis in 12.3% (7/57), and an undetermined or unspecified organism in 14.0% (8/57) patients. Overall case fatality was 44.6% (25/56). Fungal IE was associated with a significantly higher case fatality 75.0% (9/12) than that of bacterial IE 36.1% (13/36) (p = 0.02). Surgical management of post-HTx IE was observed in 35.1% (20/57) of patients. This included valve surgery for 70.0% (14/20), including the mitral valve in 50.0% (7/14), aortic valve in 35.7% (5/14), and the tricuspid valve in 14.3% (2/14) of patients. Conclusion In addition to bacterial organisms, fungi also represent a frequent cause of IE in post-HTx patients. Overall HTx patient survival in the setting of IE is poor and may be worse if caused by A. fumigatus.

Objective Gastroparesis is a debilitating condition that causes nausea, vomiting, and abdominal pain. Management includes analgesics and antiemetics, but symptoms are often refractory. Haloperidol has been utilized in the palliative care setting for similar symptoms. The study objective was to determine whether haloperidol as an adjunct to conventional therapy would improve symptoms in gastroparesis patients presenting to the emergency department (ED). Study Design and Methods This was a randomized, double-blind, placebo-controlled trial of adult ED patients with acute exacerbation of previously diagnosed gastroparesis. The treatment group received 5 mg of haloperidol plus conventional therapy (determined by the treating physician). The control group received a placebo plus conventional therapy. The severity of each subject's abdominal pain and nausea were assessed before intervention and every 15 minutes thereafter for 1 hour using a 10-point scale for pain and a 5-point scale for nausea. Primary outcomes were decreased pain and nausea 1 hour after treatment. Results Of the 33 study patients, 15 were randomized to receive haloperidol. Before treatment, the mean intensity of pain was 8.5 in the haloperidol group and 8.28 in the placebo group; mean pretreatment nausea scores were 4.53 and 4.11, respectively. One hour after therapy, the mean pain and nausea scores in the haloperidol group were 3.13 and 1.83 compared to 7.17 and 3.39 in the placebo group. The reduction in mean pain intensity therapy was 5.37 in the haloperidol group (p ≤ 0.001) compared to 1.11 in the placebo group (p = 0.11). The reduction in mean nausea score was 2.70 in the haloperidol group (p ≤ 0.001) and 0.72 in the placebo group (p = 0.05). Therefore, the reductions in symptom scores were statistically significant in the haloperidol group but not in the placebo group. No adverse events were reported. Conclusions Haloperidol as an adjunctive therapy is superior to placebo for acute gastroparesis symptoms.

Biological aging is a risk factor for the development of cardiovascular disease. The changes in the normal immune cell phenotype and function in the myocardium due to immunosenescence is the major source for cardiac distress. Cardiac resident macrophages in the heart play a critical role in the maintenance of homeostatic functions and tissue repair during myocarditis. Recently, we have demonstrated that non-tuberculosis Mycobacterium avium (NTM- common in lung infections in the elderly population in the U.S.) infection predisposes the aged mice to cardiac dysfunction; however the mechanism is not known. Here, we investigated the various subsets of myeloid cells and their contribution to the heart function in old mice. We infected young (10 weeks) and old mice (18 months) with NTM and characterized the resident and infiltrated myeloid cells. Our results revealed that before infection old mice showed elevated numbers of myeloid cells in heart tissue compared to young mice. In contrast, NTM infection (30 day post infection) significantly increased the frequency of different myeloid cell subsets in the young mice. Although, the number of cardiac macrophages in young and old mice are not significantly different in infected and uninfected mice, we found that MHCII low macrophages (cardiac resident) are significantly higher in the heart tissue of old mice than young mice before infection which significantly decreased after infection. Interestingly, we observed that MHCII high and MerTK + macrophage (infiltrated macrophages) populations are increased in young and old mice but with a higher rate in young mice. Notably, we found that the number of myeloid-derived suppressor cells (MDSCs) in the heart of aged mice is decreased by infection, which was increased in young mice. In conclusion our data indicates that the NTM infection alters the myeloid cell population and function in the aged heart and failed to maintain the normal heart function, where as in young mice, infection leads to the recruitment of myeloid cells which help to confront the infection and maintain the normal heart function. Further MDSCs accumulation in the heart of young mice after infection is responsible for anti-inflammatory effects to control the hypertrophy, fibrosis and inflammation.

Fulminant hepatic failure secondary to herpes simplex virus (HSV) is a rare complication that is associated with high mortality. Here, we describe the case of a critically ill patient with severe burns and inhalation injury who developed severe coagulopathy during her hospital stay, which was later found to be caused by HSV hepatitis. In addition, we review the current literature on HSV hepatitis. Only three prior reports document liver involvement of HSV in patients with burn. Clinical symptoms, diagnostic factors, and management of HSV hepatitis in patients with burn are presented. Because of severe immunosuppression and potentially fatal nature of this infection, clinicians should have a heightened suspicion for HSV hepatitis in burn patients with HSV mucocutaneous involvement, unexplained liver dysfunction, and severe coagulopathy, and it should prompt immediate initiation of intravenous acyclovir.

Introduction Second AutoSCT has been demonstrated to be beneficial in pts with relapsed multiple myeloma (rMM), in clinical trials. The optimal conditioning regimen for pts who receive a second transplant has not been currently established. We report our experience using an alternative conditioning regimen (ACR) with either bortezomib with high-dose melphalan (Bor.mel) or carmustine with high-dose melphalan (BCNU.mel), versus single-agent HDM in pts receiving a second AutoSCT for rMM. Methods Data was retrospectively collected and analyzed from all pts who received Bor.mel, BCNU.mel (dosing previously reported), and HDM (melphalan 140 mg/m2 or 200 mg/m2 IV) as conditioning prior to second AutoSCT for rMM at our institution. Demographics, disease risk status at initial diagnosis, disease status prior to and response to second AutoSCT, transplant related adverse events and outcomes were analyzed. Fisher's exact test was used to compare response rates between groups. Results Between 2012-2016, 82 adult pts received a second AutoSCT (50 HDM pts, 32 AC pts). The median age was 59 years in the HDM arm and 56 years in the ACR arm. The ACR arm had more high risk pts [7 (22%) vs 2 (4%)]; however, the majority of pts in both arms had standard risk rMM. All patients received HDM as conditioning with first AutoSCT. A complete remission at day 100 was observed in 19 (38%) HDM pts vs 11 (34%) ACR pts; VGPR in 23 (46%) HDM vs 12 (38%) ACR; PR 3 (6%) HDM vs 7 (22%) ACR; SD 1 (2%) HDM vs 1 (3%) ACR; and PD in 2 (4%) HDM vs 1 (3%) ACR. Two patients in the HDM arm were not evaluable at day 100 (1 death, 1 lost to follow up). There was a trend towards more favorable response (stringent CR + CR + VGPR) in patients that received HDM compared to ACR (p = 0.073). Adverse effects were similar between the two groups. The median time to neutrophil (12 days HDM vs 13 days ACR) and platelet engraftment (18 days HDM vs 18 days ACR) were similar. At last follow up, 42 (51.2%) pts were alive, 18 (36%) in the HDM arm and 24 (75%) in the ACR arm. Of the 40 pts that died, cause of death was progressive disease in 8 pts (4 pt in each group), infection related in 5 pts, other causes in 2 pts, and unknown in 25 pts. Conclusions Second autologous stem cell transplant is an effective option for relapsed and refractory multiple myeloma. Based on our analysis, HDM in second AutoSCT was associated with a more favorable response (sCR + CR + VGPR) compared to ACR, however; there were a higher percentage of high risk pts and fewer patients in the ACR arm. Further evaluation with a more robust population size in each group is warranted in addition to evaluating other alternative regimens to determine if a change in conditioning regimen with second autografts would provide better outcomes.

Objectives Children outside of family care face increased risk of threats to their well-being, have lower educational achievement, and experience adverse developmental outcomes. While it is generally accepted that early response and intervention is critical to reducing the risk of harm for children who have been separated from their families, it is not always clear what the most effective early response strategies are for assessing and addressing their immediate needs. The purpose of this review was to identify evidence-based early response strategies and interventions for improving the outcomes of children outside of family care, including children of and on the street, institutionalized children, trafficked children, children affected by conflict and disaster, and who are exploited for their labor. Methods A multi-phased, systematic evidence review was conducted on peer-reviewed and gray literature, which yielded a total of 101 documents that met the inclusion criteria and were reviewed. Results Overall there is a weak evidence base regarding assessment and early response interventions for children living outside of family care. Few studies included careful outcome measures or comparison groups. Although few proven interventions emerged, the review identified several promising early interventions and approaches. In emergency settings, family tracing and reunification is a highly effective response in regard to separated children, whereas placing children in institutional care is problematic, with the possible exception of time-limited placements of formerly recruited children in interim care centers. Livelihood supports are promising in regard to preventing and responding to children living outside family care. Other promising interventions include psychosocial support, including the use of traditional cleansing rituals as appropriate, educational supports such as Child Friendly Spaces, the maintenance of family connectedness for children of or on the streets, the use of community-based approaches that aid social integration, and approaches that enable meaningful child participation. A recurrent theme was that to be effective, all assessments and interventions must fit the context. Conclusion A strong need exists for strengthening the evidence base regarding the effectiveness of early assessments and responses to children living outside family care and for using the evidence to guide operational policy and practice. Recommendations regarding policy, practices, and research emerged from the review process.

Men who have sex with men (MSM) are at particular risk for HIV/sexually transmitted infections (STI). To investigate the European guidance used for MSM STI and HIV screening, risk level profiling and how this translated to practice, we conducted a questionnaire survey of leading physicians in the European branch of the International Union against Sexually Transmitted Infections (IUSTI). We identified that most European countries have limited guidance on screening intervals for MSM. Where risk profiling is advised, it is often left to clinicians to weight different behaviours and decide on screening frequency. Our results suggest that European MSM STI and HIV testing guidelines be developed with clear and specific recommendations around screening intervals and risk profiling. These guidelines will be particularly helpful due to rapidly evolving models of sexual healthcare, and the emergence of new providers who may benefit from guidelines that require less interpretation.

We performed micromotion experiments using electric cell-substrate impedance sensing (ECIS) on a confluent layer of 3T3 fibroblasts exposed to different low levels of the toxin cytochalasin B. This toxin is know to affect actin polymerization and to disrupt cytoskeletal structure and function in cells, changing the morphology of confluent cell cultures and altering the nature of the cellular micromotion, which is measured by ECIS as changes in impedance. By looking at several measures to characterize the long- and short-term correlations in the noise of the impedance time series, we are able to detect the effects of the toxin at concentrations down to 1 microM; there are intriguing hints that the effects may be discernible at levels as low as 0.1 microM. These measures include the power spectrum, the Hurst and detrended-fluctuation-analysis exponents, and the first zero and first 1/e crossings of the autocorrelation function. While most published work with ECIS uses only average impedance values, we demonstrate that noise analysis provides a more sensitive probe.