Necrotizing Enterocolitis Complicating Severe RSV Bronchiolitis in PICU Settings

This retrospective study aims to analyze the baseline characteristics and factors associated with poor outcomes in patients with necrotizing enterocolitis (NEC) complicating respiratory syncytial virus (RSV) infection. Using the Virtual Pediatric Systems data registry, patients under 2 years admitted to the pediatric intensive care unit (PICU) were screened. Patients with documented RSV infection and NEC, intestinal perforation, noninfectious gastroenteritis/colitis, or pneumatosis intestinalis occurring around the timing of RSV bronchiolitis diagnosis were included. Out of the screened patients, 41 were analyzed. Most patients (93%) were aged 30 days to 2 years, one-third had baseline anatomical cardiac defects, and 20% history of prematurity. Median PICU length of stay was 11.7 days. Seven patients died before hospital discharge. While not statistically significant, nonsurvivors tended to exhibit higher PRISM-3 scores, more acidemia, and lower systolic blood pressure. These findings emphasize the need for cautious assessment of gastrointestinal symptoms in critically ill patients with RSV infection.

Asthma Cases Treated With Inhaled Anesthetics or Extracorporeal Membrane Oxygenation: A Virtual Pediatric Systems Database Study of Outcomes

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) and/or inhaled anesthetics (IAs) are considered in the management of asthma when refractory to conventional therapy. We aimed to compare the outcomes of these two modalities in asthma PICU care and determine associated survival to hospital discharge among patients in a United States database.

DESIGN

Retrospective analysis using the Virtual Pediatric Systems (VPS, LLC) database.

SETTING

PICUs participating in the VPS database.

PATIENTS

Patients less than 18 years old with diagnosis of asthma treated with IA and/or ECMO from January 2010 to December 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 221 patients were included; 149 (67%) received ECMO, 62 (28%) received IA, and 10 (5%) received both interventions. We failed to identify any difference between the ECMO and IA groups in demographics, Pediatric Index of Mortality 2 percentage, Pediatric Risk of Mortality 3 score, Pediatric Logistic Organ Dysfunction score, or pre-intervention pH and Paco2 levels. Use of ECMO versus IA was associated with lower pre-intervention Pao2 (60 torr [7.99 kPa] vs 78 torr [10.39 kPa]; p < 0.001) and higher utilization of high-frequency oscillatory ventilation. We failed to identify an association between type of intervention (IA vs ECMO) and greater odds of survival (57/62 [92%] vs 128/149 [86%]; odds ratio [OR], 1.87; 95% CI, 0.67-5.21; p = 0.23). However, these data do not exclude the possibility that IA use is associated with more than five-fold greater odds of survival. ECMO use was associated with longer duration of intervention (5 vs 1.3 d; p < 0.001) and PICU length of stay (LOS) (13 vs 7 d; p < 0.001). As expected, ECMO versus IA was also associated with greater odds of undergoing bronchoscopy (34% vs 11%; OR, 3.7; 95% CI, 1.5-9.4; p = 0.004).

CONCLUSIONS

In the VPS database of asthma management cases, we failed to identify an association between ECMO versus IA use and survival to hospital discharge. However, ECMO was associated with longer duration of intervention and PICU LOS.

929 The Incidence and Outcomes of Delayed Laparoscopic Cholecystectomy and Bile Duct Exploration on a Unit Adopting Index Admission Surgery for All Comers. a Review of 5750 Patients

Aim

The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two-session approach to pancreatitis and suspected choledocholithiasis result in delayed management.

Method

Analysis of prospectively maintained data in a unit adopting “intention to treat” during the index admission. The aim was to study the incidence of previous biliary admissions and compare the operative difficulty, complications, and postoperative outcomes with index admission LC.

Results

Of 5750 LC performed 20.8% had previous biliary admissions; one in 93% and two or more in 7%. Most presented with biliary colic (39.6%) and acute cholecystitis (27.6%). A previous biliary history was associated with increased operative difficulty (p&lt;0.001), longer operating times (86.9 v 68.1 minutes, p&lt;0.001), more post-operative complications (7.5% v 5.2%, p=0.002) and longer hospital stay (8.1 v 5.5 days, p&lt;0.001). However, conversion and mortality rates showed no significant differences.

Conclusion

Index admission LC is superior to interval cholecystectomy and should be offered to all patients fit for general anaesthesia regardless of presenting complaints. Subspecialisation should be encouraged as a major factor in optimising resource utilisation and post-operative outcomes of biliary emergencies.

Evaluation of Alternative Power Sources for Operating CDC Mosquito Surveillance Traps

Several portable, rechargeable lithium-ion (Li-Ion) cell phone power banks were compared with standard 6-V gel lead-acid batteries as alternative power sources for operating mosquito surveillance equipment. In laboratory trials, ToughTested® (TT)16000 and 24000, Goal Zero Venture™ 70, and Griffin Survivor® units either met or exceeded that of sealed 6-V batteries when operating the Centers for Disease Control and Prevention (CDC) suction light traps (with incandescent light on) for an average of 24 h. No significant difference was found when continually operating traps powered by either the TT16000 or Goal Zero Venture 70 units compared with 6-V batteries (at approximately 57 h). The TT24000 unit was the only Li-Ion power bank that exceeded this threshold at an average of approximately 73 h. In field studies, there was no significant difference in species diversity or abundance of mosquitoes among the above 4 power sources when operating CDC light traps for 24 h compared with 6-V batteries. Our results indicate that portable Li-Ion cell phone power banks ≥10,050 mAh may be suitable replacements for 6-V gel lead-acid batteries when operating these light traps, especially if weight and size constraints influence the extent of mosquito surveillance during deployments.

Inhalational Anesthesia for Near-fatal Pediatric Asthma Complicated by Malignant Hyperthermia

Acute severe asthma is a commonly encountered condition in the pediatric emergency room and the pediatric intensive care unit (PICU). Its treatment involves the use of bronchodilatory agents acting on different receptors, steroids to reduce ongoing inflammation, and non-invasive or invasive mechanical ventilation to offload the increased work of breathing from the respiratory muscles. Patients refractory to these therapies may require the use of inhaled anesthetic agents and extracorporeal gas exchange (ECMO) for life-threatening asthma exacerbations. Depending on institutional protocols, the use of these therapies may vary. The use of inhaled anesthetic agents for asthma management in the PICU is infrequent and is limited to centers with specialized equipment. Commonly encountered side effects include hypotension, arrhythmias, and delirium. Malignant hyperthermia (MH) is a well-known but infrequent side effect of inhaled anesthetic use, depolarizing muscle agents, and has not been described in the PICU following the use of anesthetics for pediatric asthma.

1134 Incidence of Bile Acid Diarrhoea Post-Cholecystectomy - A Single Centre Cohort

Aim

Bile acid diarrhoea (BAD) can occur as a result of enterohepatic circulation interruption following cholecystectomy. Although up to 57.2% of patients are reported to develop post-cholecystectomy diarrhoea, this is not always because of BAD. The aim of this study was to determine the incidence of post-cholecystectomy BAD diagnosis and evaluate the current practices.

Method

This study was conducted as part of BADCAP study. The electronic records of patients underwent cholecystectomy operation at Oxford University Hospitals between January 2013 and December 2017 were retrospectively analysed. Records were matched with patients who underwent 75SeHCAT testing during the same time period. A positive 75SeHCAT testing was defined as a seven-day retention time of &lt; 15%.

Results

A total of 4327 patients underwent cholecystectomy operation. 2.05% (N = 89) investigated for diarrhoea by 75SeHCAT. Alongside 75SeHCAT, 69.7% (N = 62) had colonoscopy, 37.1% (N = 33) had CT abdomen and pelvis and 3.4% (N = 3) had MRCP/MRE. Gender wise statistics revealed females were 74.5% (N = 73) and males were 19.1% (N = 17). Median time from cholecystectomy to 75SeHCAT test was 780 days (SD +/-510 days). 70.8% (N = 63) had a positive 75SeHCAT test for BAD. IBD was confirmed in 2.2% (N = 2).

Conclusions

A small number of patients were investigated and only 1.5% were diagnosed with post-cholecystectomy diarrhoea. There was a significant time delay from operation to diagnosis. The true prevalence of BAD after cholecystectomy may be much higher and clinicians need to have an increased awareness of this condition. 75SeHCAT is a useful tool for diagnosis of bile acid diarrhoea.

O15: DISRUPTION OF THE BLOOD-SPINAL CORD BARRIER PREDICTS PERMANENT PARAPLEGIA AFTER THORACOABDOMINAL AORTIC ANEURYSM REPAIR

Introduction

Paraplegia post-thoracoabdominal aortic aneurysm (TAAA) repair remains both a devastating and poorly understood complication. We related temporal changes in cellular and protein composition of cerebrospinal fluid (CSF) to neurological outcomes after TAAA repair to gain mechanistic insights driving paraplegia.

Method

Patients undergoing TAAA repair (open or endovascular) with a CSF drain were prospectively recruited between 2016-2018. CSF was collected pre-operatively and 24-hourly until removal. Daily neurological examinations were performed by blinded neurologists to the study. CSF cell content was characterised by flow cytometry and proteome analysed by tandem-mass-tag proteomics. An in-vivo rat model was modified using 15 minutes of aortic occlusion to produce consistent paraplegia. Rats were analysed neuro-behaviourally and histologically.

Result

CSF was analysed from 52 patients (age: 70.27+/-11.4; 66% male; open (n=9), endovascular (n=43)). 12 developed paraplegia of whom 5 remained permanently-paraplegic. Demographics were comparable between paraplegics, those who recovered and without post-op neurology. Permanent paraplegia was associated with a significant infiltration of CSF CD45+ leucocytes (P&lt;0.0001). Levels of ADVS-1 was &gt;3-fold higher in permanent-paraplegics CSF versus those who recovered (P=0.0008). ADVS-1 &gt;15ng/ml predicted permanent paraplegia with 100% specificity. Pre-treatment with ADVS-1 inhibition significantly improved walking (&lt;0.001) and increased astrocytic staining in the lateral corticospinal, reticulospinal and rubrospinal tracts versus controls (P=0.03, 0.04, 0.04 respectively).

Conclusion

Permanent paraplegia is associated with shedding of ADVS-1 from parenchymal cord into CSF and blood/spinal-cord barrier disruption leading to cord oedema/leucocyte infiltration. Pre-treatment with ADVS-1 inhibition led to neurobehavioural and histological improvements offering translational hope for this devastating complication.

Take-home message

ADVS-1 is a novel biomarker of paraplegia where accurate biomarkers have proven challenging but more importantly it has proven a therapeutic target with genuine translational potential.

Endoscopic papillary large balloon dilatation for the extraction of common bile duct stones

BACKGROUND AND AIM

endoscopic papillary large balloon dilatation (EPLBD) is increasingly accepted as an appropriate option for the management of difficult common bile duct stones (CBDS). This study aimed to evaluate the safety and efficacy of EPLBD with a relatively large balloon (15-20 mm) for the extraction of difficult CBDS.

PATIENTS AND METHODS

a total of 40 patients were recruited with obstructive jaundice and dilated CBD (≥ 10 mm) subsequent to a single large CBDS of ≥ 10 mm or multiple stones (≥ 3). All patients underwent endoscopic retrograde cholangio-pancreatography (ERCP) with limited sphincterotomy and large balloon dilatation followed by stone extraction using an extraction balloon or dormia basket, without lithotripsy, stenting or further ERCP sessions.

RESULTS

successful stone extraction was achieved in 34 patients (85%) and stone extraction failure occurred in six patients (15%). Complications included minimal pancreatitis in four cases (10%), mild pancreatitis in two cases (5%), cholangitis in two cases (5%) and bleeding in two cases (5%). There were no recorded cases of perforation or mortality subsequent to the procedure.

CONCLUSION

EPLBD is a safe and efficient procedure for the extraction of difficult CBDS and may be advisable in patients with a bleeding risk or abnormal papillary anatomy.

Serum 25-OH vitamin D level in treatment-naïve systemic lupus erythematosus patients: Relation to disease activity, IL-23 and IL-17

Objectives The aim of this study was to assess the vitamin D status in treatment-naïve SLE patients and its association with clinical and laboratory markers of disease activity, including serum levels of IL-17 and IL-23. Methods Fifty-seven treatment-naïve SLE patients along with 42 matched controls were included. SLEDAI score was used to estimate disease activity. Serum levels of 25(OH) D, IL-17 and IL-23 were measured. Results The median level of 25(OH) D in SLE patients (40.8; 4-70 ng/ml) was significantly lower than in the controls (47; 25-93 ng/ml) ( P = 0.001). A total of 38.6% of SLE cases had 25 (OH) D levels < 30 ng/ml (hypovitaminosis D) vs. 4.8% of the controls ( P < 0.0001). Apart from thrombocytopenia, vitamin D was not associated with clinical signs of SLE. There were negative correlations between serum 25(OH) D and serum levels of IL-17, IL-23 and ANA (rho = -0.5, -0.8, -0.5, P ≤ 0.05) in SLE patients. Conclusion Hypovitaminosis D is prevalent in treatment naïve SLE patients. It contributes to ANA antibody production and is associated with high serum levels of IL-23 and IL-17; thus they may trigger the inflammatory process in SLE.

Predictors of re-occlusion after successful recanalization of chronic total occlusion

The objective of this study was to highlight the incidence and predictors of re-occlusion after successful recanalization of chronic total coronary occlusions.

METHODS AND RESULTS

Following successful recanalization and stent implantation in 716 coronary lesions (665 patients) with chronic total occlusion, four hundred and five (56.6%) lesions (375 patients) underwent repeat angiography within 6 months. Restenosis (> or = 50% lumen narrowing) was observed in 151 (37.3%) lesions; forty-three (10.6%) of these lesions had complete re-occlusion and constituted the study population. In this group, final angiographic minimal lumen diameter (MLD) was 2.6 +/- 0.51 mm and final percent diameter stenosis was 18 +/- 11. Univariate analysis revealed significant correlation between re-occlusion and restenotic lesions, final balloon diameter, final percent diameter stenosis, final angiographic MLD, number of stents per lesion and total stent length. By multivariate analysis, the only independent predictor of re-occlusion was total stent length (OR = 1.46, 95% CI = 1.12-1.82; p = 0.0069).

CONCLUSION

Re-occlusion occurs in about 11% of cases after stenting chronic total occlusion. The most important predictor of re-occlusion seems to be stent length.

The preoperative use of cimetidine in reducing acidity of gastric secretion

Cimetidine, SKF 92334, 1-Cyano 2-methyl -3-2 (Methylimidazole -4- ylmethylthio) ethyl guanidine, C10 H16 N6 S, a competitive antagonist of H2 histamine receptors was given as a single dose orally before induction of anaesthesia in elective and emergency surgery. The volume and pH of the gastric juice were measured in 260 patients of either sex. Cimetidine was given at different times between 0 and 6 hours and was compared with control Group A who received I.M. injection of diazepam 10 mg. and atropine sulphate 0.6 mg, and control Group B who received oral diazepam 10 mg. 1-11/2 hours preoperatively. Cimetidine had maximum effect in reducing the acidity of the gastric secretion when given 2-4 hours preoperatively. Atropine had no substantial effect in reducing the pH and volume of gastric juice when administered with cimetidine.

Safety in the use of pesticides

The need for coordination between the Egyptian Ministries of Agriculture, Health, and Manpower in order to reduce the potential hazards from pesticides is discussed. A consolidated code of safety regulations is required for the handling and use of pesticides. Regular updates of the regulations to reflect changes in techniques or information is required. Precise evaluation of environmental exposures must be made. Finally, efforts must be made to develop the proper safety attitude in each individual.

Acute upper gastrointestinal tract bleeding and recent alcohol ingestion

Alcohol ingestion is a reason for hospital admission for what may be termed trivial or even spurious gastrointestinal bleeding. This clinical entity can be recognized and hospital admission avoided. It is suggested that in the case of men under the age of 40 who present with a history of hematemesis and who are intoxicated to a variable degree but without a history of recent salicylate ingestion or previous dyspepsia, and in whom the hemoglobin level is above 13.0 g/dl it is acceptable management to send them home with instructions to seek help only if there is fresh, authenticated bleeding. This attitude is further supported by a normal blood volume measurement and the absence of blood from a gastric aspirate.

Pulmonary hypertension due to micro-thromboembolism from splenic and portal veins after portacaval anastomosis

This is a presentation of a unique case of pulmonary hypertension in a 15-year-old girl, due to micro-thromboembolism from splenoportal veins through a portacaval anastomosis.