Objectives Elevated serum phosphate levels have been associated with increased risks of cardiovascular events and death in several patient populations. The effects of serum phosphate on outcomes in patients with critical limb ischemia (CLI) have not been evaluated. In this study, we assessed the effect of abnormal phosphate levels on mortality and major limb events following surgical intervention for critical limb ischemia (CLI). Methods A retrospective review was undertaken to identify all patients at a single institution who underwent a first-time open or endovascular intervention for CLI between 2005 and 2014. Patients without recorded post-operative phosphate levels were excluded. Post-operative phosphate levels within 30-days of the initial operation were recorded and the mean was calculated. Patients were stratified according to mean phosphate levels (low <2.5, normal 2.5–4.5, high >4.5). Patient demographics, comorbidities, and operative details were compared in univariate analysis. Multivariable regression and cox-proportional hazard modeling were utilized to account for patient demographics and comorbid conditions. Results 941 patients were identified including 42(5%) with low phosphate, 768(82%) with normal phosphate, and 131(14%) with high phosphate. Patients with elevated phosphate were younger and had higher rates of congestive heart failure, diabetes, and dialysis dependence. Bypass was more common among patients with normal phosphate as compared to high or low phosphate levels. There was no difference in WiFi or TASC classification between cohorts. There were significant differences in 1-year mortality (low: 19%, normal: 17%, high: 33%, p < .01) and 3-year mortality (low 38%, normal: 34%, high: 56%, p <.01) between phosphate cohorts. Major amputation (low: 12%, normal: 12%, high: 15%) and restenosis (low: 21%, normal: 24%, high: 28%) tended toward worse outcomes among patients with elevated phosphate levels, but did not reach statistical significance. After adjustment for baseline characteristics, mortality was higher (HR: 1.7, 95% CI: 1.3–2.2) and amputation free survival was lower (HR: 1.5, 95% CI: 1.2–1.9) among patients with elevated as compared with normal phosphate levels. A subgroup analysis was then performed to assess dialysis and non-dialysis patients separately. Patients with elevated serum phosphate levels maintained a significantly higher risk of mortality in each group (Dialysis HR: 1.8 95% CI 1.2–2.6, Non-dialysis: HR 1.5, 95% CI 1.04–2.10). Conclusion Elevated phosphate levels are associated with increased mortality and decreased amputation free survival following interventions for critical limb ischemia. Future studies evaluating the effects of phosphate reduction in patients with CLI are warranted.

Background: A previously proposed immune risk profile (IRP), based on T cell phenotype and CMV serotype, is associated with mortality in the elderly and increased infections post-kidney transplant. To evaluate if NK cells contribute to the IRP and if the IRP can be predicted by a clinical T cell functional assays, we conducted a cross sectional study in renal transplant candidates to determine the incidence of IRP and its association with specific NK cell characteristics and ImmuKnow® value. Material and Methods: Sixty five subjects were enrolled in 5 cohorts designated by age and dialysis status. We determined T and NK cell phenotypes by flow cytometry and analyzed multiple factors contributing to IRP. Results: We identified 14 IRP+ [CMV seropositivity and CD4/CD8 ratio < 1 or being in the highest quintile of CD8+ senescent (28CD–/CD57+) T cells] individuals equally divided amongst the cohorts. Multivariable linear regression revealed a distinct IRP+ group. Age and dialysis status did not predict immune senescence in kidney transplant candidates. NK cell features alone could discriminate IRP– and IRP+ patients, suggesting that NK cells significantly contribute to the overall immune status in kidney transplant candidates and that a combined T and NK cell phenotyping can provide a more detailed IRP definition. ImmuKnow® value was negatively correlated to age and significantly lower in IRP+ patients and predicts IRP when used alone or in combination with NK cell features. Conclusion: NK cells contribute to overall immune senescence in kidney transplant candidates.

Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome of immune system dysregulation characterized by the phagocytosis of various cells by histiocytes in the bone marrow. HLH can present in one of the two ways: primary HLH, which is caused by mutations in genes essential to T and NK-cell function, and secondary HLH, typically caused by Epstein–Barr virus (EBV) infection or malignancy. Because of the rapid progression and high mortality of this disease, prompt diagnosis is essential to good outcomes. Here, we report the 2-month clinical course of a patient who presented with altered mental status and recurrent fever of unknown origin. Initially, he did not meet diagnostic criteria for HLH and had a negative bone marrow biopsy; however, he eventually progressed to full-blown HLH secondary to occult Hodgkin lymphoma. This case is unusual for the slow and smoldering course of the patient’s disease and highlights the importance of aggressively searching for potential malignancies to ensure the initiation of definitive therapy as soon as possible.

A term male infant was born to a healthy 24-year-old mother with antenatally diagnosed liver-up, left congenital diaphragmatic hernia (CDH) and gastroschisis. The infant was stabilised in the neonatal intensive care unit and then underwent primary repair of the CDH via left subcostal incision and silo placement for the gastroschisis. Serial silo reductions were started postoperatively and umbilical flap closure for the gastroschisis was performed on day of life 6. The patient was weaned from respiratory support, started on enteral feeds, and discharged home at 1 month of age. He was weaned from supplemental nasogastric feeds by 6 weeks of age and is currently well and thriving at 11 months of age.

Several mortality prediction models exist for patients on Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO), including the Survival after VA ECMO (SAVE) Score. Whether additional characteristics, such as body surface area (BSA), race, gender, Hispanic ethnicity, and dialysis history, affect mortality of VA ECMO patients are not as well understood. This study thus assessed such prognostic factors in these patients.