Transplantation of high risk donor livers:Machine perfusion studies to improve and predict post transplant hepatobiliary function

There currently is a shortage of suitable donor livers in the Netherlands. In 2016, waiting list mortality was 17%. In that same year 32% of all donor livers were declined for transplantation, due to an estimated high risk of complications, such as primary non-function, early allograft dysfunction en biliary complications. In this dissertation was investigated if initially declined donor lives could potentially be used for transplantation. A combined protocol of hypo- and normothermic oxygenated machine perfusion was used to resuscitate and evaluate these initially declined donor livers (DHOPE-COR-NMP trial). During normothermic (body temperature) machine perfusion the liver had to meet certain criteria to be accepted for transplantation. These criteria reflected hepatobiliary function- and injury. The perfusion solution was based on artificial haemoglobin. The use of this HBOC-201- based perfusion solution was found to be safe. Furthermore, 20% extra livers were transplanted in the UMCG in 2018 with the DHOPE-COR-NMP protocol. In another study in this dissertation pH, bicarbonate and glucose in bile were shown to be accurate predictors of histological bile duct injury. Histological bile duct injury has been associated with biliary complications post transplantation. In the final chapter of the dissertation was investigated whether dual hypothermic oxygenated machine perfusion via the portal vein and hepatic artery (DHOPE) is superior to hypothermic oxygenated machine perfusion via the portal vein alone (HOPE). Porcine livers that underwent DHOPE had less hepatobiliary injury than porcine livers that underwent HOPE

The diversity of inducible and constitutively expressed <em>erm</em>(C) genes and association to different replicon types in staphylococci plasmids

The aim of this study was to analyze the diversity of the macrolide resistance gene, erm(C) in relation to structural alterations affecting the gene expression. In addition, the association of erm(C) to mobile genetic elements (MGEs) in staphylococci mainly from Danish pigs was investigated. In total, 78 erythromycin-resistant isolates were screened for erm(C) by PCR. The erm(C) genes incl. the upstream regulatory region were sequenced and the expression types were characterized phenotypically (agar diffusion test) and genotypically (sequence analysis). Phylogenetic analysis of erm(C) was compared with structural alterations affecting the gene expression. Plasmids carrying erm(C) from seven selected isolates were fully or partially sequenced. Thirty-seven isolates were shown to be erm(C) positive and erm(C) from pigs were all constitutively expressed, mainly caused by different sized deletions (118, 111, 107, 70, 66, 16 and 3 bp) in the regulatory region. Duplication (63 bp) and substitutions were also found to cause a constitutive phenotype. Only one horse isolate had an inducible expression type. Phylogenetic analysis showed that structural alterations have happened in different erm(C) allele groups and not only in one group. Furthermore erm(C) was found mainly on plasmids (~2.4–8 kb) and gene sequence types correlated with plasmid replication (rep) gene types. One erm(C) type was linked to an IS257 element able to circularize. In conclusion, structural alterations giving rise to constitutive expression of erm(C) have happened several times in the evolution of erm(C). Interestingly, the diversity of erm(C) appears to be linked to the plasmid type or MGE carrying the gene

The Gut as Reservoir of Antibiotic Resistance: Microbial Diversity of Tetracycline Resistance in Mother and Infant

The microbiota in the human gastrointestinal tract (GIT) is highly exposed to antibiotics, and may be an important reservoir of resistant strains and transferable resistance genes. Maternal GIT strains can be transmitted to the offspring, and resistances could be acquired from birth. This is a case study using a metagenomic approach to determine the diversity of microorganisms conferring tetracycline resistance (Tcr) in the guts of a healthy mother-infant pair one month after childbirth, and to investigate the potential for horizontal transfer and maternal transmission of Tcr genes. Fecal fosmid libraries were functionally screened for Tcr, and further PCR-screened for specific Tcr genes. Tcr fosmid inserts were sequenced at both ends to establish bacterial diversity. Mother and infant libraries contained Tcr, although encoded by different genes and organisms. Tcr organisms in the mother consisted mainly of Firmicutes and Bacteroidetes, and the main gene detected was tet(O), although tet(W) and tet(X) were also found. Identical Tcr gene sequences were present in different bacterial families and even phyla, which may indicate horizontal transfer within the maternal GIT. In the infant library, Tcr was present exclusively in streptococci carrying tet(M), tet(L) and erm(T) within a novel composite transposon, Tn6079. This transposon belongs to a family of broad host range conjugative elements, implying a potential for the joint spread of tetracycline and erythromycin resistance within the infant's gut. In addition, although not found in the infant metagenomic library, tet(O) and tet(W) could be detected in the uncloned DNA purified from the infant fecal sample. This is the first study to reveal the diversity of Tcr bacteria in the human gut, to detect a likely transmission of antibiotic resistance from mother to infant GITs and to indicate the possible occurrence of gene transfers among distantly related bacteria coinhabiting the GIT of the same individual

Detection and linkage to mobile genetic elements of tetracycline resistance gene tet(M) in Escherichia coli isolates from pigs

BACKGROUND: In Escherichia coli the genes involved in the acquisition of tetracycline resistance are mainly tet(A) and tet(B). In addition, tet(M) is the most common tetracycline resistance determinant in enterococci and it is associated with conjugative transposons and plasmids. Although tet(M) has been identified in E. coli, to our knowledge, there are no previous reports studying the linkage of the tet(M) gene in E. coli to different mobile genetic elements. The aim of this study was to determine the occurrence of tet(A), tet(B), and tet(M) genes in doxycycline-resistant E. coli isolates from pigs, as well as the detection of mobile genetic elements linked to tet(M) in E. coli and its possible transfer from enterococci. RESULTS: tet(A) was the most frequently detected gene (87.9%) in doxycycline-resistant isolates. tet(M) was found in 13.1% E. coli isolates. The tet(M) gene was detected in relation with conjugative transposons in 10 out of 36 enterococci isolates analyzed but not in any of E. coli isolates positive for tet(M). Southern blot showed that in E. coli and in most of the enterococci isolates the tet(M) gene was carried on a plasmid. According to the phylogenetic analysis, E. coli contained a new tet(M) allele grouping separately. Mating experiments revealed that tet(M) was carried on a mobile element successfully transferred between enterococci and between enterococci and E. coli. CONCLUSIONS: The detection of tet(M) in E. coli isolates from pigs was higher than expected. In our study, tet(M) detected in E. coli seems not to have been transferred from enterococci, although it can not be ruled out that the horizontal transfer of this gene occurred from other intestinal tract bacteria

Post-transplant cholangiopathy:Classification, pathogenesis, and preventive strategies

Biliary complications are the most frequent cause of morbidity, re-transplantation, and even mortality after liver transplantation. In general, biliary leakage and anastomotic and non-anastomotic biliary strictures (NAS) can be recognized. There is no consensus on the exact definition of NAS and different names and criteria have been used in literature. We propose to use the term post-transplant cholangiopathy for the spectrum of abnormalities of large donor bile ducts, that includes NAS, but also intraductal casts and intrahepatic biloma formation, in the presence of a patent hepatic artery. Combinations of these manifestations of cholangiopathy are not infrequently found in the same liver and ischemia-reperfusion injury is generally considered the common underlying mechanism. Other factors that contribute to post-transplant cholangiopathy are biliary injury due to bile salt toxicity and immune-mediated injury. This review provides an overview of the various types of post-transplant cholangiopathy, the presumed pathogenesis, clinical implications, and preventive strategies

Using Intervention Mapping for Systematic Development of a Midwife-Delivered Intervention for Prevention and Reduction of Maternal Distress during Pregnancy

The authors describe how Intervention Mapping was used to develop a midwife-led intervention to prevent or reduce maternal distress during pregnancy. An extensive needs assessment showed that both pregnant women and midwives needed to be taught to recognise the vulnerability for developing maternal distress during pregnancy and how to identify maternal distress when it occurs. In addition to these mutual learning needs, women needed to learn to disclose their problems, how to handle maternal distress in their daily lives, and the value of seeking help when necessary. Midwives needed to prepare themselves to provide (collaborative) care for maternal distress. Screening and psycho-education were pathways to support self-disclosure, self-management, mobilizing support and treatment of maternal distress. Theory-based methods - such as tailoring, communicative support, individualization, advance organisers, cultural similarity, consciousness raising, elaboration, and cue altering - were built into a web-based tailored program for women. Information processing, intergroup dialogue training, verbal persuasion, providing cues, facilitation of means, and structural organization were the theory-based methods that were built into a training program and a toolbox for the midwife-delivered program. The program was introduced by means of the training given to midwives from 17 midwife-led practices in the Netherlands and proved to be effective. Finally, process and effect evaluations were planned

Dual Versus Single Oxygenated Hypothermic Machine Perfusion of Porcine Livers:Impact on Hepatobiliary and Endothelial Cell Injury

Background: Hypothermic oxygenated machine perfusion (HOPE) reduces ischemia-reperfusion injury of donor livers and is increasingly used in clinical transplantation. However, it remains unclear whether perfusion via the portal vein alone (HOPE) or via both the portal vein and hepatic artery (dual HOPE or DHOPE) is superior. Methods: Twelve porcine livers donated after circulatory death were randomized for 2 h of HOPE (n = 6) or DHOPE (n = 6), followed by 4 h of warm reperfusion with whole blood, to mimic transplantation. Hepatobiliary and endothelial cell function and injury markers were determined in perfusate and bile samples. Biopsies of bile ducts, hepatic arteries, and liver parenchyma were collected to assess histological damage and the expression of endothelial protective genes (KLF-2, eNOS, ET-1, CD31, VWF, VEGF-A). Results: There were no differences in hepatobiliary function and injury after warm reperfusion between the groups, apart from a 2-fold lower concentration of alanine aminotransferase in the perfusate (P = 0.045) and a lower peak lactate dehydrogenase in bile (P = 0.04) of livers preserved by DHOPE. Endothelial cell function and injury, as assessed by perfusate nitric oxide and von Willebrand factor antigen levels, as well as endothelial protective gene expressions, were similar between the groups. The hepatic arteries of both groups showed no microscopic evidence of injury. Conclusions: This study did not reveal major differences in hepatobiliary or endothelial function and injury after preservation by single or dual HOPE of porcine livers donated after circulatory death

Men who have sex with men more often chose daily than event-driven use of pre-exposure prophylaxis: baseline analysis of a demonstration study in Amsterdam.

The Amsterdam PrEP project is a prospective, open-label demonstration study at a large sexually transmitted infection (STI) clinic. We examined the uptake of PrEP; the baseline characteristics of men who have sex with men (MSM) and transgender persons initiating PrEP; their choices of daily versus event-driven PrEP and the determinants of these choices

I-POEMS Listening to the voices of women with a traumatic birth experience

This qualitative study, utilizing a feminist perspective, aimed to explore and articulate women's recall of emotional birth trauma experiences. The reason being that one in every five women has a negative recall of childbirth and one in every nine women has experienced birth as a traumatic event, with sometimes detrimental implications for women and their families. Thirty-six individual narrative interviews with Dutch-speaking women were conducted. Consent was obtained and interviews were audiotaped and fully transcribed. Sentences with the ‘voice of the ‘I’’ were extracted from the transcripts and were constructed into I-poems, showing four key themes: (1) The journey – unmet hopes and expectations of women during pregnancy, birth and thereafter; (2) The ‘I’ in the storm –women’s notions of painful thoughts and memories; (3) The other – women’s responses to the interaction with healthcare professionals; (4) The environment – sensory awareness of the birthingenvironment. The results described and showed the rawness and desolation of women's experiences reflected in their narratives of self, context and in relation to others, maternity care providers in specific. This study showed that acknowledging and listening to women’s voices are of merit to inform (student) midwives and other healthcare professionals who are involved with childbearing women so that the significance of this experience can be understood