The RUTIROX clinical trial aims to determine clinical predictors of respiratory failure using high-flow nasal cannula (HFNC) for acute respiratory failure (ARF) P/F ratio<200 due to COVID-19 pneumonia. Study protocol includes a change to NIV after HFNC failure, prior to endotracheal intubation (ETI). Local ethics committee approval NCT05094661. Methods: Interventional randomized study in PICU during Mar-Nov 21. In supine position HFNC was started at 60l/min Fio2 0.9, ABG and analysis were controled. If respiratory failure (defined as RR>30 or Sat<92% or P/F<80) occurred, participants were randomized to CPAP/BPAP. At day 28 ETI and death were evaluated. Statistical analysis SPSS. Chi-square tests, U-Mann Whitney and ROC analysis. Results: n=128 63% Men. Mean age 62. Mean P/F 164. 49% required NIV (28 CPAP/35 BIPAP). 21.9% required ETI. Mortality 9.3%. Advanced age, diabetes, neoplasia, low P/F ratio, low pO2 and high initial LDH value, were significantly more frequent in HFNC failure group (p-value <0.05). Area Under the ROC curve (AUC) of initial LDH is 0,65 (level of 300 U/L) and LDH at 48h 0,67. AUC of P/F is 0,69 for survival. No differences were found between NIV groups. Conclusions: Older age, higher degree of ARF and high LDH value are factors associated with HFNC failure. Despite presenting high intragroup failure frequency values, ETI rate and mortality rate were lower than those reported in other series.

Background: T-cell response against SARS-CoV-2 is essential for disease control and to understand correlates of protection against various disease outcomes in COVID-19. This makes T-cell measurement an important tool for clinical management. Aims: To evaluate the IFN-γ-releasing T-cell response against spike (S), nucleocapsid (N) and membrane (M) SARS-CoV-2 antigens using an ELISPOT-based assay in acute, convalescent, and vaccinated individuals. Methods: Blood samples were collected from acute (n=71) and convalescent (n=59) individuals classified according to severity; and from vaccinated (n=48) and non-vaccinated (n=80) controls. After stimulating with S, N and M antigens overnight, T-cell response was measured (T-SPOT® Discovery SARS-CoV-2. Oxford Immunotec, UK). IgG against S and N were also measured. Results: S antigen triggered the highest number of T-cell responses (46%), although responses against N and M were in a large percentage of individuals. The majority of convalescent individuals (93%) had a reactive T-cell response more than 200 days after diagnosis. Such response increased with severity. Acute patients had fewer positive responses (68%). S antigen triggered most responses in vaccinated controls, but only in half of them T-cell response was observed after the second dose. A higher percentage of individuals showed IgG response compared to IFN-γ-releasing T-cell responses, and moderate correlations between both quantitative responses were seen. Conclusions: T-cell response against SARS-CoV-2 is low during acute phase but may increase over time, as seen in convalescent individuals. Regarding vaccinated individuals, half had a positive test result after the second dose.

Epstein-Barr virus (EBV) is a herpesvirus whose only reservoir host is the human. It is transmitted by oropharyngeal secretions. Primary EBV infection is usually asymptomatic, but sometimes it causes infectious mononucleosis with fever, lymphadenopathies, splenomegaly and pharyngitis. Acute infection is diagnosed by serology (heterophile or specific antibodies). Immunofluorescence and molecular biologic techniques may be used to demonstrate the presence of EBV in biopsy specimens. Mild and transient elevations of serum aminotransferases are common, thus liver biopsy is usually not necessary to confirm the diagnosis. Severe cholestasis is rare (5%). We describe a patient with cholestatic hepatitis and acute EBV infection with atypical lymphocytes and positive anti-VCA IgM. The patient had taken drugs (ibuprofen, paracetamol and valerian). The bad evolution of the patient, the history of exposure to drugs, and the few cases of cholestatic hepatitis due to EBV infection reported, led us to consider liver biopsy. Molecular biologic techniques confirmed the presence of EBV in liver tissue however histologic features did not exclude the toxic aetiology or the concomitant effect of drugs and EBV infection.

Epstein-Barr virus (EBV) is a herpesvirus whose only reservoir host is the human. It is transmitted by oropharyngeal secretions. Primary EBV infection is usually asymptomatic, but sometimes it causes infectious mononucleosis with fever, lymphadenopathies, splenomegaly and pharyngitis. Acute infection is diagnosed by serology (heterophile or specific antibodies). Immunofluorescence and molecular biologic techniques may be used to demonstrate the presence of EBV in biopsy specimens. Mild and transient elevations of serum aminotransferases are common, thus liver biopsy is usually not necessary to confirm the diagnosis. Severe cholestasis is rare (5%). We describe a patient with cholestatic hepatitis and acute EBV infection with atypical lymphocytes and positive anti-VCA IgM. The patient had taken drugs (ibuprofen, paracetamol and valerian). The bad evolution of the patient, the history of exposure to drugs, and the few cases of cholestatic hepatitis due to EBV infection reported, led us to consider liver biopsy. Molecular biologic techniques confirmed the presence of EBV in liver tissue however histologic features did not exclude the toxic aetiology or the concomitant effect of drugs and EBV infection.

Celiac disease can present great clinical heterogeneity. Its association with a series of intestinal and non-intestinal diseases, whether immunologically mediated or otherwise, presents a higher than normal frequency. We present a patient with celiac disease and Budd-Chiari syndrome of unknown cause. This association has previously been described only in isolated cases in northern Africa. The appearance of this case in Spain reveals that the coexistence of both processes in a single patient is unlikely to be due to environmental or geographical factors.

BACKGROUND/AIMS:We compared the response to interferon-alpha 2a in 35 patients with antibody to HBeAg (anti-HBe) and 20 patients with HBeAg in serum, and histological features of chronic hepatitis B.METHODOLOGY:Patients were treated with 4.5-6 MU of interferon-alpha 2a, three times a week for 12 months, and followed for 30.8 +/- 13.5 additional months.RESULTS:All of them had elevated serum levels of aminotransferases and positive test for hepatitis B virus-DNA in serum. Patients with anti-HBe-positive chronic hepatitis were older and had higher serum aminotransferase levels than HBeAg-positive patients, but no differences were seen between both groups with respect to sex, history of acute hepatitis, mode of transmission of the infection or histological appearance before interferon therapy. Serum levels of alanine transaminase became normal and hepatitis B virus-DNA undetectable by PCR at the end of therapy in 25 (71%) of anti-HBe-positive patients and in 10 (50%) of HBeAg-positive patients (P > 0.05). Although 10 (29%) of the anti-HBe-positive and none of the HBeAg-positive patients relapsed, no significant difference was seen in the rate of sustained response (43% vs. 50%, respectively). The histological improvement was similar in both groups.CONCLUSIONS:The results of this study indicated that biochemical, virological and histological response to 12-month interferon-alpha 2a therapy was similar in patients with anti-HBe antibody than in patients with the classical HBeAg-positive of chronic hepatitis B.

Abdominal ultrasonographic findings of Gaucher's disease had been reported, but a specific pattern has not been described. We report here a patient with an abdominal sonographic pattern which was concluded to be strongly suggestive of Gaucher's disease: solid focal splenic lesions with different patterns (hypoechoic, hiperechoic and mixed nodules associated with hypoechoic irregular areas) and bright liver and spleen echo pattern with posterior beam attenuation. Gaucher's disease was subsequently confirmed by determination of leukocyte beta-glucosidase activity and mutations of glucocerebrosidase gene.

BACKGROUND We wanted to investigate the influence of viral genotype on the severity of liver injury and response to interferon and whether the level of viremia differs in accordance with genotype, severity of liver disease, and response to interferon in patients with hepatitis C virus (HCV) infection. METHODS We studied 118 patients with HCV-related liver disease. HCV genotypes were determined with a line probe assay, and serum HCV RNA levels with a competitive reverse transcription polymerase chain reaction assay. RESULTS HCV type 1b was the most prevalent genotype (88%). It was present in 100% of cirrhotic patients, with or without hepatocellular carcinoma (HCC), but only in 78% of patients with chronic hepatitis (P < 0.001). The response to interferon was better in patients infected with non-1b HCV genotypes (P = 0.002). In a multivariate analysis non-1b HCV genotypes and a low hepatic fibrosis correlated with a favorable response to interferon. Among patients with chronic hepatitis those infected with HCV type 1b were older (P < 0.001), and age was the only independent factor associated with HCV type 1b. Viremia levels differed neither between genotypes nor in response to interferon and was significantly lower in patients with cirrhosis and HCC. CONCLUSIONS HCV 1b was associated with more severe liver disease and a worse response to interferon therapy. Non-1b genotypes and a lower liver fibrosis were the only independent predictors of a favorable response to interferon. Levels of HCV viremia differed neither among different genotypes nor in response to interferon and decreased with advanced liver disease.

OBJECTIVE:To compare the two most frequently used methods of percutaneous endoscopic gastrostomy: Pull-string Ponsky-Gauderer type and Push-over-wire Sachs-Vine gastrostomy.PATIENTS AND METHODS:Forty-four patients with oral feeding incapacity were prospectively randomized to one of the two methods of percutaneous endoscopic gastrostomy. In 22 patients the Ponsky-Gauderer type were used and in the other 22 the Sachs-Vine gastrostomy were employed. In every case the gastrostomy tube was replaced 4-5 months after its placement by a Flexiflo tube. The mean follow-up of the patients was 7.3 months (range: 4-18).RESULTS:Gastrostomy was successful in every case. No differences were found between the two procedures in technical difficulties or complications during gastrostomy placement. Wound infection occurred in 6 patients (13%), 3 in each group, and in all cases it was cured with topic antibiotic treatment administered through the gastrostomy. Tube dislodgement was observed in 3 patients in the Ponsky-Gauderer group (soft internal with-holder). The only significant difference between the two procedures was found at the removal of the gastrostomy tube. In the Sachs-Vine type the removal of the tube was always endoscopically performed (due to the presence of a rigid internal with-holder), while the Ponsky-Gauderer type was always done by traction (soft internal with-holder). No related procedure mortality was found with any of the two techniques.CONCLUSION:Both percutaneous endoscopic gastrotomy techniques are similar in efficacy, safety and morbidity and they prove to be a valid alternative to surgical gastrostomy in patients with oral feeding incapacity.

Interferon (INF) is the treatment of choice in active chronic hepatitis C although the optimum therapeutic schedule remains undefined to date. One forty-eight patients with active chronic hepatitis C were included in a randomized controlled study to compare the therapeutic efficacy of 2 types of recombinant alpha IFN: alpha-2b IFN and alpha-2a IFN. Twelve patients were excluded from the study for different reasons. The groups were made up of 34 untreated patients (group I), 68 patients treated with 5 MU of alpha-2b IFN three times per week for 12 months (group II) and 32 patients with 6 MU of alpha-2a IFN three times per week for one year (group III). On finalization of the treatment 39 patients from group II (57%) and 20 (63%) from group III showed normal transaminases (p > 0.05) while this was not so in any patient from group I (p < 0.001). HCV infection of less than 5 years was significantly associated with complete biochemical response. During the post treatment follow up (16.2 +/- 11.1 months; range: 6-45 months) the transaminase levels reelevated in 26 (67%) responding patients from group II and in 12 (60%) patients from group III (p > 0.05). Therefore complete biochemical response was maintained in only 12 (19%) of the patients from group II and in 8 (25%) of the patients from group III (p > 0.05). Liver biopsy was carried out in the 3 post treatment months in 15 patients from group I, 29 from group II and 18 patients from group III with all the rebiopsied patients from groups II and III having demonstrated complete or partial response to IFN.(ABSTRACT TRUNCATED AT 250 WORDS)