Surveillance system integration: reporting the results of a global multicountry survey

OBJECTIVES

Currently, there is no comprehensive picture of the global surveillance landscape. This survey examines the current state of surveillance systems, levels of integration, barriers and opportunities for the integration of surveillance systems at the country level, and the role of national public health institutes (NPHIs).

STUDY DESIGN

This was a cross-sectional survey of NPHIs.

METHODS

A web-based survey questionnaire was disseminated to 110 NPHIs in 95 countries between July and August 2022. Data were descriptively analysed, stratified by World Health Organization region, World Bank Income Group, and self-reported Integrated Disease Surveillance (IDS) maturity status.

RESULTS

Sixty-five NPHIs responded. Systems exist to monitor notifiable diseases and vaccination coverage, but less so for private, pharmaceutical, and food safety sectors. While Ministries of Health usually lead surveillance, in many countries, NPHIs are also involved. Most countries report having partially developed IDS. Surveillance data are frequently inaccessible to the lead public health agency and seldomly integrated into a national public health surveillance system. Common challenges to establishing IDS include information technology system issues, financial constraints, data sharing and ownership limitations, workforce capacity gaps, and data availability.

CONCLUSIONS

Public health surveillance systems across the globe, although built on similar principles, are at different levels of maturity but face similar developmental challenges. Leadership, ownership and governance, supporting legal mandates and regulations, as well as adherence to mandates, and enforcement of regulations are critical components of effective surveillance. In many countries, NPHIs play a significant role in integrated disease surveillance.

Diagnostic accuracy of serum matrix metalloproteinase-7 as a biomarker of biliary atresia in a large North American cohort

BACKGROUND AIMS

High levels of serum matrix metalloproteinase-7 (MMP-7) have been linked to biliary atresia (BA), with wide variation in concentration cutoffs. We investigated accuracy of serum MMP-7 as a diagnostic biomarker in a large North American cohort.

APPROACH RESULTS

MMP-7 was measured in serum samples of 399 cholestatic infants in the Prospective Database of Infants with Cholestasis study of the Childhood Liver Disease Research Network, 201 infants with BA and 198 with non-BA cholestasis (age median: 64 and 59 days, p=0.94). MMP-7 was assayed on antibody-bead fluorescence (single-plex) and time resolved-fluorescence energy transfer (TR-FRET) assays. Discriminative performance of MMP-7 was compared with other clinical markers. On the single-plex assay, MMP-7 generated an area under receiver operating curve (AUROC) of 0.90 (confidence interval [CI] 0.87-0.94). At cutoff 52.8 ng/mL, it produced sensitivity=94.03%, specificity=77.78%, positive predictive value=64.46%, and negative predictive value=96.82% for BA. AUROC for gamma-glutamyl transferase (GGT)=0.81 (CI 0.77-0.86), stool color=0.68 (CI 0.63-0.73), and pathology=0.84 (CI 0.76-0.91). Logistic regression models of MMP-7 with other clinical variables individually or combined showed an increase for MMP-7+GGT AUROC to 0.91 (CI 0.88-0.95). Serum concentrations produced by TR-FRET differed from single-plex, with optimal cutoff of 18.2 ng/mL. Results were consistent within each assay technology and generated similar AUROCs.

CONCLUSIONS

Serum MMP-7 has high discriminative properties to differentiate BA from other forms of neonatal cholestasis. MMP-7 cutoff values vary according to assay technology. Using MMP-7 in evaluation of cholestatic infants may simplify diagnostic algorithms and shorten time to hepatoportoenterostomy.

Investigation of acute severe hepatitis in children: A review of liver transplant data, Canada, 2021-2022

An increase in severe acute hepatitis of unknown etiology was first reported in the United Kingdom in April 2022. Following this report, the Public Health Agency of Canada connected with three paediatric liver transplant centres across Canada to determine if an increase in liver transplants was noted. Data demonstrated no observable increase in the number of transplants conducted in 2022. These data in conjunction with a federal, provincial, territorial investigation provided insight into the situation in Canada.

A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Background

Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant.

Purpose

The primary aim of our study is to report a case of NALF with successful liver transplant.

Method

We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation.

Result(s)

This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29.

Conclusion(s)

Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less.

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Disclosure of Interest

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MICROBIOME & MICROBIAL THERAPY

A258 SEVERE ACUTE HEPATITIS OF UNKNOWN ORIGIN WITH RAPID PROGRESSION TO PAEDIATRIC ACUTE LIVER FAILURE IN A CHILD

Background

Severe acute hepatitis (SAH) of unknown origin among children has been a major public health concern globally in recent times, with >1010 cases reported to WHO, including 28 in Canada as of July2022. The clinical syndrome in all identified cases (median age 3, IQR 2-5 yrs) was acute hepatitis with progression to paediatric acute liver failure (PALF) and need for liver transplantation (LT) in 5.4-13%. Human adenovirus (HAdV), particularly serotypes 40 and 41, remains the most common pathogen detected around the time of presentation in upto 70%. HAdV hepatitis is a rarity in the immunocompetent. The role of adenovirus in SAH remains unclear and investigations continue

Purpose

To report the case of a child meeting the WHO case definition of SAH of unknown origin in whom adenovirus was detected with rapid progression to PALF requiring LT

Method

Case report and literature review

Result(s)

A previously healthy 4year-old girl presented to us with a 1week history of abdominal pain and vomiting followed by onset of jaundice. 1month prior to presentation, she had an episode of conjunctivitis. Examination revealed a well-appearing girl with icterus, hepatosplenomegaly with no stigmata of chronic liver disease and no features of hepatic encephalopathy. Laboratory results on day of presentation revealed transaminases >10 times upper limit of normal (ALT 4686U/L, AST 5986U/L), total bilirubin-233μmol/L (conjugated bilirubin-153μmol/L) and INR-1.6. Work up for viral hepatitis(A-E), metabolic, autoimmune, genetic or mechanical causes of hepatitis was negative (Table 1). HAdV was detected by PCR in blood (9700 copies/mL), stool and nasopharyngeal swab. Treatment with cidofovir (1mg/kg/dose) was started on day8 after presentation.By day11, laboratory parameters had worsened with ALT 1293U/L, AST 2326U/L, total bilirubin 331μmol/L, INR-9.1 and LT was considered. With failure to improve over the next 48hrs, she received a living donor LT on day13 after presentation and had an uneventful post-transplant course. At the time of writing this report, she was 41 days post-transplant, doing well on immunosuppression with tacrolimus and tapering dose of steroids. Histopathological examination of liver showed extensive hepatocyte loss of upto 80%, replaced by ductules, in a background of mild hepatitis (patchy pan-lobular inflammation with minimal portal inflammation) and no significant fibrosis. Electron microscopy (EM) showed patchy hemophagocytosis. No evidence of HAdV on immunohistochemical stains or EM was identified. These findings are directly in line with what others have reported, namely a lack of direct toxic effect of virus on liver tissue

Image

Conclusion(s)

This case highlights the potential for rapid progression to PALF and need for LT in a child SAH of unknown origin. Early identification and diagnosis of PALF is important and should be followed by transfer to a LT center. As previously described by others, HAdV was detected, but its role in pathogenesis of this clinical syndrome remains elusive

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Correction: Expanding the utility of the ROX index among patients with acute hypoxemic respiratory failure

[This corrects the article DOI: 10.1371/journal.pone.0261234.].

Serum biomarkers correlated with liver stiffness assessed in a multicenter study of pediatric cholestatic liver disease

BACKGROUND AND AIMS

Detailed investigation of the biological pathways leading to hepatic fibrosis and identification of liver fibrosis biomarkers may facilitate early interventions for pediatric cholestasis.

APPROACH AND RESULTS

A targeted enzyme-linked immunosorbent assay-based panel of nine biomarkers (lysyl oxidase, tissue inhibitor matrix metalloproteinase (MMP) 1, connective tissue growth factor [CTGF], IL-8, endoglin, periostin, Mac-2-binding protein, MMP-3, and MMP-7) was examined in children with biliary atresia (BA; n = 187), alpha-1 antitrypsin deficiency (A1AT; n = 78), and Alagille syndrome (ALGS; n = 65) and correlated with liver stiffness (LSM) and biochemical measures of liver disease. Median age and LSM were 9 years and 9.5 kPa. After adjusting for covariates, there were positive correlations among LSM and endoglin ( p = 0.04) and IL-8 ( p < 0.001) and MMP-7 ( p < 0.001) in participants with BA. The best prediction model for LSM in BA using clinical and lab measurements had an R2 = 0.437; adding IL-8 and MMP-7 improved R2 to 0.523 and 0.526 (both p < 0.0001). In participants with A1AT, CTGF and LSM were negatively correlated ( p = 0.004); adding CTGF to an LSM prediction model improved R2 from 0.524 to 0.577 ( p = 0.0033). Biomarkers did not correlate with LSM in ALGS. A significant number of biomarker/lab correlations were found in participants with BA but not those with A1AT or ALGS.

CONCLUSIONS

Endoglin, IL-8, and MMP-7 significantly correlate with increased LSM in children with BA, whereas CTGF inversely correlates with LSM in participants with A1AT; these biomarkers appear to enhance prediction of LSM beyond clinical tests. Future disease-specific investigations of change in these biomarkers over time and as predictors of clinical outcomes will be important.

Risk of variceal hemorrhage and pretransplant mortality in children with biliary atresia

BACKGROUND AND AIMS

The natural history of gastroesophageal variceal hemorrhage (VH) in biliary atresia (BA) is not well characterized. We analyzed risk factors, incidence, and outcomes of VH in a longitudinal multicenter study.

APPROACH AND RESULTS

Participants enrolled in either an incident (Prospective Database of Infants with Cholestasis [PROBE]) or prevalent (Biliary Atresia Study of Infants and Children [BASIC]) cohort of BA were included. Variceal hemorrhage (VH) was defined based on gastrointestinal bleeding in the presence of varices accompanied by endoscopic or nontransplant surgical intervention. Cumulative incidence of VH and transplant-free survival was compared based on features of portal hypertension (e.g., splenomegaly, thrombocytopenia) and clinical parameters at baseline in each cohort (PROBE: 1.5 to 4.5 months after hepatoportoenterostomy [HPE]; BASIC: at enrollment > 3 years of age). Analyses were conducted on 869 children with BA enrolled between June 2004 and December 2020 (521 in PROBE [262 (51%) with a functioning HPE] and 348 in BASIC). The overall incidence of first observed VH at 5 years was 9.4% (95% CI: 7.0-12.4) in PROBE and 8.0% (5.2-11.5) in BASIC. Features of portal hypertension, platelet count, total bilirubin, aspartate aminotransferase (AST), albumin, and AST-to-platelet ratio index at baseline were associated with an increased risk of subsequent VH in both cohorts. Transplant-free survival at 5 years was 45.1% (40.5-49.6) in PROBE and 79.2% (74.1-83.4) in BASIC. Two (2.5%) of 80 participants who had VH died, whereas 10 (12.5%) underwent transplant within 6 weeks of VH.

CONCLUSIONS

The low risk of VH and associated mortality in children with BA needs to be considered in decisions related to screening for varices and primary prophylaxis of VH.

Impact of regurgitant orifice ellipticity on quantitation of tricuspid regurgitation using the proximal isovelocity surface area method

Funding Acknowledgements

Type of funding sources: None.

Background

The proximal isovelocity surface area (PISA) method to quantify tricuspid regurgitation (TR) severity relies on the geometric assumption of a circular, planar regurgitant orifice.  However, the TR orifice is often non-circular resulting in underestimation of TR severity when calculating the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol).

Purpose

To evaluate the effect of ellipticity of the tricuspid annulus on EROA-PISA correlation with quantitative Doppler (EROA-Dopp), and three-dimensional vena contracta area (VCA-3D).

Methods

Patients undergoing both transthoracic (TTE) and transesophageal (TEE) echo evaluation of TR severity were included in this study. Regurgitant orifice ellipticity was calculated as the ratio of the vena contracta maximum and minimum widths (VC-Ratio). Quantification of EROA and RegVol were performed on TTE for EROA-PISA and EROA-Dopp. Vena contract area was measured on TEE (VCA-3D).

Results

Of 44 total pts, the median age was 80 ± 9, 61% were female, 89% had atrial fibrillation, (86%) had functional TR, 32% were graded as severe, and 71% had a EROA-PISA ≥ 0.4 cm2. Median VC-Ratio was 1.3 (IQR 1.1-1.8) and was used to differentiate more circular orifices (VC-Ratio &lt;1.3) from more elliptical orifices (VC-Ratio ≥1.3) (Table). EROA-PISA was significantly smaller compared to EROA-Dopp and VCA-3D in the whole group as well as elliptical subgroups (p &lt; 0.0001 for all).  There was no significant difference between EROA-Dopp and 3D-VCA for the whole group, or in circular or elliptical orifice subgroups (p &gt; 0.5 for all). EROA-PISA correlated better with both EROA-Dopp and VCA-3D in circular compared to elliptical orifices (Table). EROA-Dopp and VCA-3D demonstrated high correlation for both circular and elliptical orifices (r = 0.76, p &lt; 0.0001 and r = 0.77, p &lt; 0.0001 respectively).

Conclusion

Our study demonstrated that there is a significant difference in quantitative measurements of tricuspid regurgitant orifice area, with EROA-PISA significantly underestimating both EROA-Dopp and VCA-3D.  In more circular orifices, the EROA-PISA correlation was higher, however EROA-Dopp and VCA-3D were still significantly larger. Whether EROA-Dopp and VCA-3D are more predictive of outcomes requires further study. Abstract Table 1  Abstract Figure 1

Correlation between standard and adjusted echocardiographic quantitative methods for evaluating tricuspid regurgitation severity

Funding Acknowledgements

Type of funding sources: None.

Background

Current guidelines advocate for a multi-parametric approach to echocardiographic quantitation of tricuspid regurgitation (TR). The primary quantitative measure of TR severity uses the proximal isovelocity surface area (PISA) method to calculate effective regurgitant orifice area (EROA) and regurgitant volume (RegVol). However, EROA-PISA may underestimate TR severity due to low flow and tethering of the tricuspid leaflets.

Purpose

The purpose of this study was to compare standard EROA-PISA quantitation of TR to alternative quantitative measures, including quantitative Doppler (EROA-Doppler), flow- and angle-corrected PISA method (EROA-Corrected), and three-dimensional vena contracta area (3D-VCA), in addition to the comparison of calculated RegVol-PISA, RegVol-Doppler, and RegVol-3DVCA.

Methods

Patients undergoing both transthoracic (TTE) and transesophageal (TEE) echocardiographic evaluation of TR severity for transcatheter treatment were included in this study. Patients were excluded if they had ≥ moderate aortic regurgitation. TTE measurements of EROA-PISA and RegVol-PISA were performed as per American Society of Echocardiography guidelines. EROA-Doppler was performed by quantifying RegVol-Doppler (diastolic stroke volume using biplane annular area, minus left ventricular outflow stroke volume) and deriving EROA. EROA-Corrected was calculated by adjusting for both aliasing velocity and leaflet angle as per published methods. 3D-VCA was measured on TEE performed within 14 days of TTE.

Results

Of 44 consecutive patients, the median age was 80 ± 9 years, 61% were female, and 89% had atrial fibrillation. Most patients (86%) had functional TR, 71% had a EROA-PISA ≥ 0.4 cm2. Table 1 shows the EROA and RegVol results for each method.  EROA-PISA and RegVol-PISA were significantly lower than EROA-Doppler and RegVol-Doppler, as well as 3D-VCA and RegVol-3DVCA (all p &lt; 0.0001). There was no significant difference between EROA-Doppler and 3D-VCA (p = 0.51), and RegVol-Doppler and RegVol-3DVCA (p = 0.66).  EROA-Corrected reduced the absolute difference with EROA-Doppler (51% to 33%, p &lt; 0.0001) and 3D-VCA (52% to 32%, p &lt; 0.0001), but remained statistically lower than EROA-Doppler and 3D-VCA. Although EROA-PISA was strongly correlated to EROA-Doppler (r = 0.75, p &lt; 0.0001) and 3D-VCA (r = 0.68, p &lt; 0.0001), the correlation between EROA-Doppler and 3D-VCA was greatest (r = 0.77, p &lt; 0.0001). Adjusting EROA-PISA for angle and flow demonstrated improved correlation to EROA-Doppler without affecting correlation to 3D-VCA (Figure 1).

Conclusion

Our study demonstrated that EROA-PISA significantly underestimates the severity of TR by EROA-Doppler and 3D-VCA. Although PISA correction methods reduced the underestimation, both EROA-Corrected and RegVol-Corrected remained significantly lower. EROA-Doppler and 3D-VCA and the calculated RegVol by each method, were closely correlated and not significantly different. Abstract Table 1  Abstract Figure 1

Expanding the utility of the ROX index among patients with acute hypoxemic respiratory failure

BACKGROUND

Delaying intubation in patients who fail high-flow nasal cannula (HFNC) may result in increased mortality. The ROX index has been validated to predict HFNC failure among pneumonia patients with acute hypoxemic respiratory failure (AHRF), but little information is available for non-pneumonia causes. In this study, we validate the ROX index among AHRF patients due to both pneumonia or non-pneumonia causes, focusing on early prediction.

METHODS

This was a retrospective observational study in eight Singapore intensive care units from 1 January 2015 to 30 September 2017. All patients >18 years who were treated with HFNC for AHRF were eligible and recruited. Clinical parameters and arterial blood gas values at HFNC initiation and one hour were recorded. HFNC failure was defined as requiring intubation post-HFNC initiation.

RESULTS

HFNC was used in 483 patients with 185 (38.3%) failing HFNC. Among pneumonia patients, the ROX index was most discriminatory in pneumonia patients one hour after HFNC initiation [AUC 0.71 (95% CI 0.64-0.79)], with a threshold value of <6.06 at one hour predicting HFNC failure (sensitivity 51%, specificity 80%, positive predictive value 61%, negative predictive value 73%). The discriminatory power remained moderate among pneumonia patients upon HFNC initiation [AUC 0.65 (95% CI 0.57-0.72)], non-pneumonia patients at HFNC initiation [AUC 0.62 (95% CI 0.55-0.69)] and one hour later [AUC 0.63 (95% CI 0.56-0.70)].

CONCLUSION

The ROX index demonstrated moderate discriminatory power among patients with either pneumonia or non-pneumonia-related AHRF at HFNC initiation and one hour later.

Ventilatory performance of AMBU® AuraGain™ and LMA® Supreme™ in laparoscopic surgery: A randomised controlled trial

The Ambu® AuraGain™ (Ambu A/S, Ballerup, Denmark) is a newer phthalate-free, single-use supraglottic device with the advantage of a facility for tracheal intubation if necessary intraoperatively. We compared the oropharyngeal leak pressures and other performance variables between the AMBU AuraGain and the LMA® Supreme™ (Teleflex Medical, Athlone, Co. Westmeath, Ireland) in patients undergoing laparoscopic cholecystectomy and preperitoneoscopic inguinal herniorrhaphy with carbon dioxide insufflation under controlled ventilation. We recruited 120 American Society of Anesthesiologists physical status class I-3 patients between the ages of 21 and 80 years undergoing laparoscopic cholecystectomy or preperitoneoscopic inguinal herniorrhaphy into this single-centre randomised controlled trial. The primary outcome measure was the oropharyngeal leak pressures. Secondary outcomes included insertion parameters, ventilatory characteristics and postoperative sequelae. The AuraGain had slightly but significantly higher oropharyngeal leak pressures than the LMA Supreme (mean (standard deviation) 26.1 (6.9) versus 21.4 (4.7) cmH₂O, P < 0.010). The overall insertion success of the AuraGain was comparable to the LMA Supreme (AuraGain 58/60 (96.7%); LMA Supreme 56/59 (94.9%), P = 0.679). The AuraGain was deemed more difficult to insert than the LMA Supreme, with 26/60 (43.3%) of AuraGain insertions graded easy versus 48/59 (81.4%) of LMA Supreme, P < 0.001. The mean time to insertion of the AuraGain was slightly longer than the LMA Supreme, 32.2 (10.5) versus 28.3 (12.0) s, P < 0.001. Intraoperative device failure occurred following carbon dioxide insufflation in one AuraGain and three LMA Supremes, bringing the perioperative success rate of AuraGain and LMA Supreme to 95% and 89.8%, respectively, P = 0.322. No cases of regurgitation and aspiration occurred, and minor postoperative complications were similar. The AuraGain exhibited higher oropharyngeal leak pressures than the LMA Supreme, but was slightly more difficult to insert. The higher oropharyngeal leak pressures suggest that ventilation might be less affected by high peak inspiratory pressures when using the AuraGain than the LMA Supreme.

A Case Series on Genotype and Outcome of Liver Transplantation in Children with Niemann-Pick Disease Type C

BACKGROUND

To report on clinical presentation and outcomes of children who underwent liver transplantation (LTx) and were subsequently diagnosed to have Niemann-Pick type C (NPC).

METHODS

Retrospective, descriptive, multi-centre review of children diagnosed with NPC who underwent LTx (2003-2018). Diagnosis was made by filipin skin test or genetic testing.

RESULTS

Nine children were identified (six centres). Neonatal acute liver failure was the most common indication for LTx (seven children). Median age at first presentation: 7 days (range: 0-37). The most prevalent presenting symptoms: jaundice (8/9), hepatosplenomegaly (8/9) and ascites (6/9). 8/9 children had a LTx before the diagnosis of NPC. Genetic testing revealed mutations in NPC1 correlating with a severe biochemical phenotype in 5 patients. All 9 children survived beyond early infancy. Seven children are still alive (median follow-up time of 9 (range: 6-13) years). Neurological symptoms developed in 4/7 (57%) patients at median 9 (range: 5-13) years following LTx.

CONCLUSION

Early diagnosis of NPC continues to be a challenge and a definitive diagnosis is often made only after LTx. Neurological disease is not prevented in the majority of patients. Genotype does not appear to predict neurological outcome after LTx. LTx still remains controversial in NPC.

High-flow nasal cannula therapy: A multicentred survey of the practices among physicians and respiratory therapists in Singapore

BACKGROUND

Use of high-flow nasal cannula (HFNC) has become a regular intervention in the intensive care units especially in patients coming in with hypoxaemic respiratory failure. Clinical practices may differ from published literature.

OBJECTIVES

The objective of this study was to determine the clinical practices of physicians and respiratory therapists (RTs) on the use of HFNC.

METHODS

A retrospective observational study looking at medical records on HFNC usage from January 2015 to September 2017 was performed and was followed by a series of questions related to HFNC practices. The survey involved physicians and RTs in intensive care units from multiple centres in Singapore from January to April 2018. Indications and thresholds for HFNC usage with titration and weaning practices were compared with the retrospective observational study data.

RESULTS

One hundred twenty-three recipients (69.9%) responded to the survey and reported postextubation (87.8%), pneumonia in nonimmunocompromised (65.9%), and pneumonia in immunocompromised (61.8%) patients as the top three indications for HFNC. Of all, 39.8% of respondents wanted to use HFNC for palliative intent. Similar practices were observed in the retrospective study with the large cohort of 63% patients (483 of the total 768 patients) where HFNC was used for acute hypoxaemic respiratory failure and 274 (35.7%) patients to facilitate extubation. The survey suggested that respondents would initiate HFNC at a lower fraction of inspired oxygen (FiO₂), higher partial pressure of oxygen to FiO₂ ratio, and higher oxygen saturation to FiO₂ ratio for nonpneumonia patients than patients with pneumonia. RTs were less likely to start HFNC for patients suffering from pneumonia and interstitial lung disease than physicians. RTs also preferred adjustment of FiO₂ to improve oxygen saturations and noninvasive ventilation for rescue.

CONCLUSIONS

Among the different intensive care units surveyed, the indications and thresholds for the initiation of HFNC differed in the clinical practices of physicians and RTs.

Sequential paternal haploidentical donor liver and HSCT in EPP allow discontinuation of immunosuppression post-organ transplant

BACKGROUND

EPP is characterized by photosensitivity and by liver disease. When LT is performed in EPP, recurrence often occurs in the allograft due to ongoing protoporphyrin production in bone marrow. Therefore, curative treatment requires allogeneic HSCT after LT. Long-term immunosuppression could be spared by using the same donor for both transplants.

METHODS

A 2-year-old girl with EPP in liver failure underwent liver transplant from her father. Transfusion and apheresis therapy were used to lower protoporphyrin levels before and after liver transplant. Ten weeks after liver transplant, she underwent HSCT, using the same donor. Conditioning was with treosulfan, fludarabine, cyclophosphamide, and ATG. GVHD prophylaxis was with abatacept, methotrexate, MMF, and tacrolimus. We followed the patient's erythrocyte protoporphyrin and liver and skin health for 2 years after transplant.

RESULTS

After hematopoietic stem cell engraftment, a decline in protoporphyrin levels was observed, with clinical resolution of photosensitivity. Liver biopsies showed no evidence of EPP. Mild ACR occurred and responded to steroid pulse. Two years post-HSCT, the patient has been weaned off all immunosuppression and remains GVHD and liver rejection free.

CONCLUSIONS

Sequential liver and HSCT from the same haploidentical donor are feasible in EPP. This strategy can allow for discontinuation of immune suppression.

Predictors and outcomes of high-flow nasal cannula failure following extubation: A multicentre observational study

INTRODUCTION

Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed post-extubation HFNC.

METHODS

We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC.

RESULTS

Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke was an independent predictor of HFNC failure (odds ratio 2.48, 95% confidence interval 1.83-3.37). Failed HFNC, as compared to successful HFNC, was associated with increased median ICU length of stay (14 versus 7 days, P<0.001), ICU mortality (14.6% versus 2.0%, P<0.001) and hospital mortality (29.3% versus 12.3%, P=0.006).

CONCLUSION

Post-extubation HFNC failure, especially in patients with stroke as a comorbidity, remains a clinical challenge and predicts poorer clinical outcomes. Our observational study highlights the need for future prospective trials to better identify patients at high risk of post-extubation HFNC failure.

625 Health Economics and Safety of Frontline Carers in the COVID-19 Era: Time to Abolish Routine Group and Save For Emergency Appendicectomies?

Introduction

Face of healthcare, patient safety and protection of healthcare providers has been completely transformed with global health pandemic. However, emergency surgical procedures must still be performed, with the commonest being appendicectomy.

It is common practice across National Health Service trusts to collect a group and save (G&S) sample pre-operatively which increases healthcare staff exposure to the patient and increased use of personal protective equipment in this pandemic.

Method

Prospective study of adult patients undergoing emergency appendicectomy since the transformation of emergency care with COVID-19 induced restrictions compared with patients undergoing the same operation before the pandemic.

Results

179 adult patients underwent emergency appendicectomy over 6-months in 2019–2020, 60 patients in the 12 weeks period from the start of the transformed emergency services due to the pandemic. Pre-operative G&S samples were taken for 60(33.5%) patients in the pre COVID-19 period, whereas 7(11.6%) were taken for patients undergoing appendicectomy during the pandemic. None of the patients in either group had intra-operative blood loss of more than 500 millilitres and none of them required peri-operative blood transfusion

Conclusions

Our study demonstrates that the routine pre-operative G&S can safely be abandoned as a routine practice for all patients undergoing emergency appendicectomy.

A215 MDR3 DEFICIENCY MIMICKING WILSON DISEASE

Background

The chronic phenotype of ALF includes a broad differential diagnosis. Class III multi-drug resistance P-glycoprotein 3 (MDR3) deficiency, also referred to as progressive familial intrahepatic cholestasis type 3, is an autosomal recessive genetic disorder. It is caused by a defect on the ABCB4 gene located on chromosome 7, which encodes MDR3. MDR3 is responsible for transporting phosphatidylcholine across the canalicular membrane, thereby allowing it to be incorporated into bile micelles. MDR3 deficiency results in increased levels of free bile acids and detergent bile. Progressive cholangiopathy ensues from this detergent bile and indirectly leads to cholestasis and liver failure in severe cases. Significantly increased urinary and hepatic copper (Cu), which are hallmarks of Wilson disease, have also been reported in patients with acute hepatitis and cholestasis including patients with MDR3 deficiency

Aims

We report a case of a girl who presented with a chronic phenotype of PALF, who had multiple features of Wilson disease and so was treated as such until genetic analysis confirmed MDR3 deficiency

Methods

Results

A 6 year old girl presented to the ED with a 1mth history of epistaxis and a 1wk history of abdominal pain and distension, facial edema, pallor and fever. Her family history was significant for parental consanguinity and maternal itch during pregnancy. On examination she had clubbing, scleral icterus and a distended abdomen with hepatosplenomegaly. Her bloodwork showed bicytopenia (HGB 53 & Plts 63) along with liver dysfunction (INR 2.9, albumin 25, conjugated bilirubin 9) and raised liver enzymes (transaminases & GGT &gt;10xULN). Her total serum bile acids were raised at 134. An US showed hepatosplenomegaly with multiple hyperechoic nodules and perisplenic varices. She was extensively worked up for malignancy, autoimmune and metabolic disease. Serum ceruloplasmin was reduced, ophthalmology examination showed no KF rings and her 24hr urinary Cu was 10xULN. Liver Cu quantification was markedly raised at 40xULN. Liver biopsy showed cirrhosis with fibrosis related minimal non-specific portal and septal inflammation. Additionally, complete loss of canalicular staining on immunohistochemistry for MDR3 protein was noted, suggestive of MDR3 deficiency. Based on the Cu levels, a provisional diagnosis of Wilson disease was made and Cu chelation therapy was commenced pending genetic testing. A cholestatic gene panel subsequently showed homozygous pathogenic variant for the ABCB4 gene. Trientine was stopped and she was commenced on ursodeoxycholic acid. Though biochemically she remains largely unchanged, she is clinically stable whilst awaiting a liver transplant

Conclusions

This case highlights the diagnostic difficulties associated with Cu test result interpretation in patients with chronic cholestatic liver disease and urges a thorough consideration of alternative diagnoses of PALF

Funding Agencies

None

A57 VALPROATE INDUCED DRESS SYNDROME CAUSING MIXED LIVER INJURY

Background

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome occurs with 1 in every 1,000 to 10,000 drug exposures and has a mortality rate of up to 10%. It is one mechanism by which medications can induce liver injury with elevated liver enzymes seen in the majority of cases. In children, aromatic anticonvulsants are the drugs most commonly associated with DRESS syndrome. Valproate, a non-aromatic anti-epileptic, is not known to have a heightened risk of hypersensitivity syndromes and is often the anti-epileptic of choice in patients who develop hypersensitivity syndromes from other anti-epileptics. Valproate hepatotoxicity is normally caused by its inhibition of fatty acid transport and mitochondrial β-oxidation; vanishing bile duct syndrome is also reported.

Aims

We present a case, to the best of our knowledge the first in paediatrics, in which valproate causes DRESS syndrome and a secondary, predominantly cholestatic, liver injury.

Methods

Literature review and case report.

Results

A previously healthy 14-year-old girl was diagnosed with new-onset seizures and started on valproate. Three weeks later, she developed a pruritic exanthem. Despite discontinuing her valproate, the rash persisted and she developed fever and jaundice. She was admitted to the ICU at the Hospital for Sick Children with a diagnosis of DRESS syndrome (RegiSCAR DRESS score 7) for treatment with IV steroids. At admission, she had a skin eruption, fever, leukocytosis (22.86 x109/L), eosinophilia (1.03x109/L), atypical lymphocytes (1.62 x109/L), lymphadenopathy, and internal organ involvement (BiliC 138, GGT 501, INR 1.3, ALT 543, AST 370, Crt 109). Of note, her EBV PCR was positive. By discharge, her rash improved and kidney function normalized. Her cholestasis persisted, despite improvement in her transaminases and eosinophilia (BiliC 163, INR 1.0, GGT 338, ALT 506, AST 220, Eos 0.98x109/L). She was discharged home on an oral steroid wean, ursodeoxycholic acid, levocarnitine, and levetiracetam. Upon reaching a daily dose of 20mg of prednisone, her rash and pruritus worsened, she had lost 7kg, and she was readmitted for IV steroids. Her rash improved within 4 days and she was discharged on a slower steroid taper, with the addition of cholestyramine and insulin for steroid induced diabetes. At present (2 ½ months after diagnosis), she continues her oral steroids and has persistent liver injury and pruritus.

Conclusions

We report the first paediatric case of valproate induced DRESS syndrome causing a significant cholestatic presentation with otherwise preserved liver synthetic function. The prolonged cholestasis and pruritus may be a result of the natural course of DRESS syndrome, EBV reactivation/infection, or polypharmacy. Early recognition of DRESS syndrome as a mechanism of valproate induced liver injury in children is essential for earlier diagnosis and initiation of targeted therapy.

Funding Agencies

None

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Influenza increases invasive meningococcal disease risk in temperate countries

OBJECTIVES

Invasive meningococcal disease (IMD) is a severe bacterial infection that displays wintertime seasonality in temperate countries. Mechanisms driving seasonality are poorly understood and may include environmental conditions and/or respiratory virus infections. We evaluated the contribution of influenza and environmental conditions to IMD risk, using standardized methodology, across multiple geographical regions.

METHODS

We evaluated 3276 IMD cases occurring between January 1999 and December 2011 in 11 jurisdictions in Australia, Canada, France and the United States. Effects of environmental exposures and normalized weekly influenza activity on IMD risk were evaluated using a case-crossover design. Meta-analytic methods were used to evaluate homogeneity of effects and to identify sources of between-region heterogeneity.

RESULTS

After adjustment for environmental factors, elevated influenza activity at a 2-week lag was associated with increased IMD risk (adjusted odds ratio (OR) per standard deviation increase 1.29; 95% confidence interval, 1.04-1.59). This increase was homogeneous across the jurisdictions studied. By contrast, although associations between environmental exposures and IMD were identified in individual jurisdictions, none was generalizable.

CONCLUSIONS

Using a self-matched design that adjusts for both coseasonality and case characteristics, we found that surges in influenza activity result in an acute increase in population-level IMD risk. This effect is seen across diverse geographic regions in North America, France and Australia. The impact of influenza infection on downstream meningococcal risk should be considered a potential benefit of influenza immunization programmes.

Incidence of new-onset diabetes mellitus and association with mortality in childhood solid organ transplant recipients: a population-based study

BACKGROUND

Precise estimates of the long-term risk of new-onset diabetes and its impact on mortality among transplanted children are not known.

METHODS

We conducted a cohort study comparing children undergoing solid organ (kidney, heart, liver, lung and multiple organ) transplant (n = 1020) between 1991 and 2014 with healthy non-transplanted children (n = 7 134 067) using Ontario health administrative data. Outcomes included incidence of diabetes among transplanted and non-transplanted children, the relative hazard of diabetes among solid organ transplant recipients, overall and at specific intervals posttransplant, and mortality among diabetic transplant recipients.

RESULTS

During 56 019 824 person-years of follow-up, the incidence rate of diabetes was 17.8 [95% confidence interval (CI) 15-21] and 2.5 (95% CI 2.5-2.5) per 1000 person-years among transplanted and non-transplanted children, respectively. The transplant cohort had a 9-fold [hazard ratio (HR) 8.9; 95% CI 7.5-10.5] higher hazard of diabetes compared with those not transplanted. Risk was highest within the first year after transplant (HR 20.7; 95% CI 15.9-27.1), and remained elevated even at 5 and 10 years of follow-up. Lung and multiple organ recipients had a 5-fold (HR 5.4; 95% CI 3.0-9.8) higher hazard of developing diabetes compared with kidney transplant recipients. Transplant recipients with diabetes had a three times higher hazard of death compared with those who did not develop diabetes (HR 3.3; 95% CI 2.3-4.8).

CONCLUSIONS

The elevated risk of diabetes in transplant recipients persists even after a decade, highlighting the importance of ongoing surveillance. Diabetes after transplantation increases the risk of mortality among childhood transplant recipients.

A North American Expert Opinion Statement on Sarcopenia in Liver Transplantation

Loss of muscle mass and function, or sarcopenia, is a common feature of cirrhosis and contributes significantly to morbidity and mortality in this population. Sarcopenia is a main indicator of adverse outcomes in this population, including poor quality of life, hepatic decompensation, mortality in patients with cirrhosis evaluated for liver transplantation (LT), longer hospital and intensive care unit stay, higher incidence of infection following LT, and higher overall health care cost. Although it is clear that muscle mass is an important predictor of LT outcomes, many questions remain, including the best modality for assessing muscle mass, the optimal cut-off values for sarcopenia, the ideal timing and frequency of muscle mass assessment, and how to best incorporate the concept of sarcopenia into clinical decision making. For these reasons, we assembled a group of experts to form the North American Working Group on Sarcopenia in Liver Transplantation to use evidence from the medical literature to address these outstanding questions regarding sarcopenia in LT. We believe sarcopenia assessment should be considered in all patients with cirrhosis evaluated for liver transplantation. Skeletal muscle index (SMI) assessed by computed tomography constitutes the best-studied technique for assessing sarcopenia in patients with cirrhosis. Cut-off values for sarcopenia, defined as SMI < 50 cm² /m² in male and < 39 cm² /m² in female patients, constitute the validated definition for sarcopenia in patients with cirrhosis. Conclusion: The management of sarcopenia requires a multipronged approach including nutrition, exercise, and additional pharmacological therapy as deemed necessary. Future studies should evaluate whether recovery of sarcopenia with nutritional management in combination with an exercise program is sustainable as well as how improvement in muscle mass might be associated with improvement in clinical outcomes.

Diagnosis, Outcome, and Management of Chylous Ascites Following Pediatric Liver Transplantation

Data on postoperative chylous ascites (CA) after pediatric liver transplantation (LT) are scarce. This retrospective study was conducted to identify the incidence, risk factors, management, and outcomes of postoperative CA in a large single-center pediatric LT cohort (2000-2016). The study cohort comprised 317 LTs (153 living donors and 164 deceased donors) in 310 recipients with a median age of 2.7 years. The incidence of CA was 5.4% (n = 17), diagnosed after a median time of 10 days after LT. Compared with chylomicron detection in peritoneal fluid (the gold standard), a triglyceride cutoff value of 187 mg/dL in peritoneal fluid showed insufficient sensitivity (31%) for CA diagnosis. In univariate logistic regression analyses, ascites before LT, younger age, and lower weight, height, and height-for-age z score at LT were associated with CA. Symptomatic management of CA included peritoneal drain (100%) and diuretics (76%). Therapeutic interventions included very low-fat or medium-chain triglyceride-rich diets (94%) and intravenous octreotide (6%), leading to CA resolution in all patients. CA was associated with prolonged hospital length of stay (LOS; 40 days in the CA group versus 24 days in the non-CA group; P = 0.001) but not with reduced patient or graft survival rates after a median follow-up time of 14 years. In conclusion, CA in the pediatric LT recipient is a relatively uncommon complication associated with increased hospital LOS and morbidity. Measurement of chylomicrons is recommended in patients with ascites that is more severe or persistent than expected. Dietary interventions are effective in most patients.

The experiences of parents and caregiver(s) whose child received an organ from a living anonymous liver donor

BACKGROUND

Anonymous living donor transplantation is a potential strategy to address the shortage of available organs for transplant. A living anonymous donor (LAD) is a donor with no biological connection and whose identity is unknown to the recipient. This study captured the lived experiences of pediatric liver transplant recipient families whose child received an organ from a LAD.

METHODS

Qualitative data collection and analysis were guided by a theoretical framework of phenomenology. Data analysis highlighted themes through an inductive process of reviewing transcript paragraphs to code for significant statements that represented key concepts and captured depth of experience.

RESULTS

A total of nine interviews were conducted with 10 participants. Data analysis yielded themes of emotional turbulence through their transplant journey. Pre-transplant experiences were characterized by feelings of helplessness and desperation. Receiving a LAD transplant prompted shock, relief, and acceptance of the donation. Post-transplant experiences were characterized by altered life-perspectives and varied levels of connectedness to the donor, marked by gratitude and concern for donor well-being.

CONCLUSION

Anonymous donation in liver transplantation is perceived by recipient families as a remarkable gift and a viable donor option. Our preliminary findings can be used to inform strategy development regarding future delivery of care.

Risk assessment strategies for early detection and prediction of infectious disease outbreaks associated with climate change

A new generation of surveillance strategies is being developed to help detect emerging infections and to identify the increased risks of infectious disease outbreaks that are expected to occur with climate change. These surveillance strategies include event-based surveillance (EBS) systems and risk modelling. The EBS systems use open-source internet data, such as media reports, official reports, and social media (such as Twitter) to detect evidence of an emerging threat, and can be used in conjunction with conventional surveillance systems to enhance early warning of public health threats. More recently, EBS systems include artificial intelligence applications such machine learning and natural language processing to increase the speed, capacity and accuracy of filtering, classifying and analysing health-related internet data. Risk modelling uses statistical and mathematical methods to assess the severity of disease emergence and spread given factors about the host (e.g. number of reported cases), pathogen (e.g. pathogenicity) and environment (e.g. climate suitability for reservoir populations). The types of data in these models are expanding to include health-related information from open-source internet data and information on mobility patterns of humans and goods. This information is helping to identify susceptible populations and predict the pathways from which infections might spread into new areas and new countries. As a powerful addition to traditional surveillance strategies that identify what has already happened, it is anticipated that EBS systems and risk modelling will increasingly be used to inform public health actions to prevent, detect and mitigate the climate change increases in infectious diseases.

Could exotic mosquito-borne diseases emerge in Canada with climate change?

Of the 3,500 species of mosquitoes worldwide, only a small portion carry and transmit the mosquito-borne diseases (MBDs) that cause approximately half a million deaths annually worldwide. The most common exotic MBDs, such as malaria and dengue, are not currently established in Canada, in part because of our relatively harsh climate; however, this situation could evolve with climate change. Mosquitoes native to Canada may become infected with new pathogens and move into new regions within Canada. In addition, new mosquito species may move into Canada from other countries, and these exotic species may bring exotic MBDs as well. With high levels of international travel, including to locations with exotic MBDs, there will be more travel-acquired cases of MBDs. With climate change, there is the potential for exotic mosquito populations to become established in Canada. There is already a small area of Canada where exotic Aedes mosquitoes have become established although, to date, there is no evidence that these carry any exotic (or already endemic) MBDs. The increased risks of spreading MBDs, or introducing exotic MBDs, will need a careful clinical and public health response. Clinicians will need to maintain a high level of awareness of current trends, to promote mosquito bite prevention strategies, and to know the laboratory tests needed for early detection and when to report laboratory results to public health. Public health efforts will need to focus on ongoing active surveillance, public and professional awareness and mosquito control. Canadians need to be aware of the risks of acquiring exotic MBDs while travelling abroad as well as the risk that they could serve as a potential route of introduction for exotic MBDs into Canada when they return home.

The Impact of Increased Allocation Priority for Children Awaiting Liver Transplant: A Liver Simulated Allocation Model (LSAM) Analysis

OBJECTIVE

The aim of the study was to investigate the impact of prioritizing infants, children, adolescents, and the sickest adults (Status 1) for deceased donor livers. We compared outcomes under two "SharePeds" allocation schema, which prioritize children and Status 1 adults for national sharing and enhanced access to pediatric donors or all donors younger than 35 years, to outcomes under the allocation plan approved by the Organ Procurement and Transplant Network in December 2017 (Organ Procurement and Transplantation Network [OPTN] 12-2017).

METHODS

The 2017 Liver Simulated Allocation Model and Scientific Registry of Transplant Recipients data on all US liver transplant candidates and liver offers 7/2013 to 6/2016 were used to predict waitlist deaths, transplants, and post-transplant deaths under the OPTN 12-2017 and SharePeds schema.

RESULTS

Prioritizing national sharing of pediatric donor livers with children (SharePeds 1) would decrease waitlist deaths for infants (<2 years, P = 0.0003) and children (2-11 years, P = 0.001), with no significant change for adults (P = 0.13). Prioritizing national sharing of all younger than 35-year-old deceased donor livers with children and Status 1A adults (SharePeds 2) would decrease waitlist deaths for infants, children, and all Status 1A/B patients (P < 0.0001 for each). SharePeds 1 and 2 would increase the number of liver transplants done in infants, children, and adolescents compared to the OPTN-2017 schema (P < 0.00005 for all age groups). Both SharePeds schema would increase the percentage of pediatric livers transplanted into pediatric recipients.

CONCLUSIONS

Waitlist deaths could be significantly decreased, and liver transplants increased, for children and the sickest adults, by prioritizing children for pediatric livers and with broader national sharing of deceased donor livers.

A randomized clinical trial of age and genotype-guided tacrolimus dosing after pediatric solid organ transplantation

BACKGROUND

Tacrolimus pharmacokinetics are influenced by age and CYP3A5 genotype with CYP3A5 expressors (CYP3A5*1/*1 or *1/*3) being fast metabolizers. However, the benefit of genotype-guided dosing in pediatric solid organ transplantation has been understudied.

OBJECTIVE

To determine whether age and CYP3A5 genotype-guided starting dose of tacrolimus result in earlier attainment of therapeutic drug concentrations.

SETTING

Single hospital-based transplant center.

METHODS

This was a randomized, semi-blinded, 30-day pilot trial. Between 2012 and 2016, pediatric patients listed for solid organ transplant were consented and enrolled into the study. Participants were categorized as expressors, CYP3A5*1/*1 or CYP3A5*1/*3, and nonexpressors, CYP3A5*3/*3. Patients were stratified by age (≤ or > 6 years) and randomized (2:1) after transplant to receive genotype-guided (n = 35) or standard (n = 18) starting dose of tacrolimus for 36-48 hours and were followed for 30 days.

RESULTS

Median age at transplant in the randomized cohort was 2.1 (0.75-8.0) years; 24 (45%) were male. Participants in the genotype-guided arm achieved therapeutic concentrations earlier at a median (IQR) of 3.4 (2.5-6.6) days compared to those in the standard dosing arm of 4.7 (3.5-8.6) days (P = 0.049), and had fewer out-of-range concentrations [OR (95% CI) = 0.60 (0.44, 0.83), P = 0.002] compared to standard dosing, with no difference in frequency of adverse events between the two groups.

CONCLUSIONS

CYP3A5 genotype-guided dosing stratified by age resulted in earlier attainment of therapeutic tacrolimus concentrations and fewer out-of-range concentrations.

Incidence of hyperglycemia and diabetes and association with electrolyte abnormalities in pediatric solid organ transplant recipients

Background

Posttransplant hyperglycemia is an important predictor of new-onset diabetes after transplantation, and both are associated with significant morbidity and mortality. Precise estimates of posttransplant hyperglycemia and diabetes in children are unknown. Low magnesium and potassium levels may also lead to diabetes after transplantation, with limited evidence in children.

Methods

We conducted a cohort study of 451 pediatric solid organ transplant recipients to determine the incidence of hyperglycemia and diabetes, and the association of cations with both endpoints. Hyperglycemia was defined as random blood glucose levels ≥11.1 mmol/L on two occasions after 14 days of transplant not requiring further treatment. Diabetes was defined using the American Diabetes Association Criteria. For magnesium and potassium, time-fixed, time-varying and rolling average Cox proportional hazards models were fitted to evaluate the association with hyperglycemia and diabetes.

Results

Among 451 children, 67 (14.8%) developed hyperglycemia and 27 (6%) progressed to diabetes at a median of 52 days (interquartile range 22-422) from transplant. Multi-organ recipients had a 9-fold [hazard ratio (HR) 8.9; 95% confidence interval (CI) 3.2-25.2] and lung recipients had a 4.5-fold (HR 4.5; 95% CI 1.8-11.1) higher risk for hyperglycemia and diabetes, respectively, compared with kidney transplant recipients. Both magnesium and potassium had modest or no association with the development of hyperglycemia and diabetes.

Conclusions

Hyperglycemia and diabetes occur in 15 and 6% children, respectively, and develop early posttransplant with lung or multi-organ transplant recipients at the highest risk. Hypomagnesemia and hypokalemia do not confer significantly greater risk for hyperglycemia or diabetes in children.

Extreme hepatic resections for the treatment of advanced hepatoblastoma: Are planned close margins an acceptable approach?

BACKGROUND

Orthotopic liver transplantation (OLT) is considered the standard for children with hepatoblastoma (HB) in whom complete surgical resection is not possible. However, OLT is not always available or feasible.

OBJECTIVE

To describe the outcome of children with HB who were initially deemed unresectable and underwent complex hepatectomy with planned close margins, and ultimately avoided OLT.

METHODS

Demographic data, surgical and pathologic details, and survival information were collected from children treated for HB between January 2010 to December 2015.

RESULTS

Among six children (median age 12 months (3-41 months)), PRETEXT classification was III (n = 2), III/IV (n = 1), and IV (n = 3). Patients received a median of six cycles (range 4-7) of platinum-based induction chemotherapy; five received doxorubicin. Experienced pediatric surgeons performed extended right and left hepatectomy in five and one patients, respectively, with assistance of an experienced liver transplant surgeon (n = 4). Microscopic margins were positive (n = 2) and negative but close (n = 4; 2-5 mm). Two patients required vascular reconstruction of the vena cava. At median follow-up of 3.3 years (1.7-4.6 years), there was no evidence of local recurrence. One patient had recurrence of pulmonary disease 3 months after surgery.

CONCLUSIONS

Patients with advanced HB treated with complex surgical resections with positive or close negative margins had good outcomes without OLT. We suggest that planned positive or close microscopic margins in highly selected HB patients may spare the morbidity of OLT and offer an alternative for those ineligible for OLT. Our experience illustrates the importance of a multidisciplinary team specialized in the management of liver tumors.

Liver transplantation for children with acute liver failure associated with secondary hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening systemic disease, characterized by overwhelming stimulation of the immune system and categorized as primary or secondary types. Occasionally, acute liver failure (ALF) may dominate the clinical presentation. Given the systemic nature of HLH and risk of recurrence, HLH is considered by many a contraindication to liver transplantation (LT). The aim of this study is to review our single-center experience with LT in children with secondary HLH and ALF (HLH-ALF). This is a cross-sectional, retrospective study of children with secondary HLH-ALF that underwent LT in 2005-2014. Of 246 LTs, 9 patients (3 males; median age, 5 years; range, 0.7-15.4 years) underwent LT for secondary HLH-ALF. Disease progression was rapid with median 14 days (range, 6-27 days) between first symptoms and LT. Low fibrinogen/high triglycerides, elevated ferritin, hemophagocytosis on liver biopsy, and soluble interleukin 2 receptor levels were the most commonly fulfilled diagnostic criteria; HLH genetic studies were negative in all patients. Immunosuppressive therapy after LT included corticosteroids adjusted to HLH treatment protocol and tacrolimus. Thymoglobulin (n = 5), etoposide (n = 4), and alemtuzumab (n = 2) were used in cases of recurrence. Five (56%) patients experienced HLH recurrence, 1 requiring repeat LT, and 3 died. Overall graft and patient survival were 60% and 67%, respectively. Six patients are alive and well at a median of 24 months (range, 15-72 months) after transplantation. In conclusion, LT can be beneficial in selected patients with secondary HLH-ALF and can restore good health in an otherwise lethal condition. Liver Transplantation 22 1245-1253 2016 AASLD.

Does Spanish instruction for emergency medicine resident physicians improve patient satisfaction in the emergency department and adherence to medical recommendations?

BACKGROUND

After emergency department (ED) discharge, Spanish-speaking patients with limited English proficiency are less likely than English-proficient patients to be adherent to medical recommendations and are more likely to be dissatisfied with their visit.

OBJECTIVES

To determine if integrating a longitudinal medical Spanish and cultural competency curriculum into emergency medicine residency didactics improves patient satisfaction and adherence to medical recommendations in Spanish-speaking patients with limited English proficiency.

METHODS

Our ED has two Emergency Medicine Residency Programs, University Campus (UC) and South Campus (SC). SC program incorporates a medical Spanish and cultural competency curriculum into their didactics. Real-time Spanish surveys were collected at SC ED on patients who self-identified as primarily Spanish-speaking during registration and who were treated by resident physicians from both residency programs. Surveys assessed whether the treating resident physician communicated in the patient's native Spanish language. Follow-up phone calls assessed patient satisfaction and adherence to discharge instructions.

RESULTS

Sixty-three patients self-identified as primarily Spanish-speaking from August 2014 to July 2015 and were initially included in this pilot study. Complete outcome data were available for 55 patients. Overall, resident physicians spoke Spanish 58% of the time. SC resident physicians spoke Spanish with 66% of the patients versus 45% for UC resident physicians. Patients rated resident physician Spanish ability as very good in 13% of encounters - 17% for SC versus 5% for UC. Patient satisfaction with their ED visit was rated as very good in 35% of encounters - 40% for SC resident physicians versus 25% for UC resident physicians. Of the 13 patients for whom Spanish was the language used during the medical encounter who followed medical recommendations, ten (77%) of these encounters were with SC resident physicians and three (23%) encounters were with UC resident physicians.

CONCLUSION

Preliminary data suggest that incorporating Spanish language and cultural competency into residency training has an overall beneficial effect on patient satisfaction and adherence to medical recommendations in Spanish-speaking patients with limited English proficiency.

Stressful Life Events of Dental Students and Salivary Immunoglobulin A

To study the perceived sources of stressful events in dental students and the relationships between their self-perceived stress levels and salivary IgA. Undergraduates as well as postgraduates at the Faculty of Dentistry, National University of Singapore were surveyed one month after the new term. A 38-item dental environmental stress (DES) questionnaire, with subscales of academic work (AW), clinical factors (CF), faculty and administration factors (FA) and personal factors (PF), was used to identify the potential stressors in the dental environment. A 4-point perceived stress scale was used to rank their self-perceived stress levels. Enzyme linked immunosorbent assay method was used to determine the salivary IgA level. One hundred and thirty students (81.3% - valid response rate) participated in the study. Overall, students ranked AW with the highest score (mean 2.76), followed by CF (2.67), FA (2.24) and PF (2.16). Among the 38 items of DES questionnaire, 1st year students perceived “fear of being unable to catch up if behind” as the most stressful event (mean 3.30). For 2nd and 3rd year students, examination and grades had the highest scores (mean 3.28, 3.19, respectively). Completing graduation requirements was the most important stressor for 4th year students (mean 3.89). Postgraduates perceived atmosphere created by clinical faculty was most stressful to them (mean 3.05). The mean total perceived stress scores were highest (22.1) in 1st year students and lowest (21.0) in postgraduates, however, no significant different among various classes. First year students had the lowest IgA secretion rates (geometric mean [GM] 46.8 μg/min), significantly lower (p<0.05) than postgraduates (GM 79.4 μg/min). An inverse correlation was noted between perceived stress scale and log IgA secretion rates (r=-0.20, p=0.002.). AW was also significantly inversely correlated with salivary IgA (r=-0.18, p=0.04). Dental students in different academic years perceived different important stressors. Salivary IgA secretion rate correlated inversely with self perceived stress.

Liver transplantation for children with acute liver failure associated with secondary hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening systemic disease, characterized by overwhelming stimulation of the immune system and categorized as primary or secondary types. Occasionally, acute liver failure (ALF) may dominate the clinical presentation. Given the systemic nature of HLH and risk of recurrence, HLH is considered by many a contraindication to liver transplantation (LT). The aim of this study is to review our single-center experience with LT in children with secondary HLH and ALF (HLH-ALF). This is a cross-sectional, retrospective study of children with secondary HLH-ALF that underwent LT in 2005-2014. Of 246 LTs, 9 patients (3 males; median age, 5 years; range, 0.7-15.4 years) underwent LT for secondary HLH-ALF. Disease progression was rapid with median 14 days (range, 6-27 days) between first symptoms and LT. Low fibrinogen/high triglycerides, elevated ferritin, hemophagocytosis on liver biopsy, and soluble interleukin 2 receptor levels were the most commonly fulfilled diagnostic criteria; HLH genetic studies were negative in all patients. Immunosuppressive therapy after LT included corticosteroids adjusted to HLH treatment protocol and tacrolimus. Thymoglobulin (n = 5), etoposide (n = 4), and alemtuzumab (n = 2) were used in cases of recurrence. Five (56%) patients experienced HLH recurrence, 1 requiring repeat LT, and 3 died. Overall graft and patient survival were 60% and 67%, respectively. Six patients are alive and well at a median of 24 months (range, 15-72 months) after transplantation. In conclusion, LT can be beneficial in selected patients with secondary HLH-ALF and can restore good health in an otherwise lethal condition. Liver Transplantation 22 1245-1253 2016 AASLD.

Prioritizing Zoonotic Diseases: Differences in Perspectives Between Human and Animal Health Professionals in North America

Zoonoses pose a significant burden of illness in North America. Zoonoses represent an additional threat to public health because the natural reservoirs are often animals, particularly wildlife, thus eluding control efforts such as quarantine, vaccination and social distancing. As there are limited resources available, it is necessary to prioritize diseases in order to allocate resources to those posing the greatest public health threat. Many studies have attempted to prioritize zoonoses, but challenges exist. This study uses a quantitative approach, conjoint analysis (CA), to overcome some limitations of traditional disease prioritization exercises. We used CA to conduct a zoonoses prioritization study involving a range of human and animal health professionals across North America; these included epidemiologists, public health practitioners, research scientists, physicians, veterinarians, laboratory technicians and nurses. A total of 699 human health professionals (HHP) and 585 animal health professionals (AHP) participated in this study. We used CA to prioritize 62 zoonotic diseases using 21 criteria. Our findings suggest CA can be used to produce reasonable criteria scores for disease prioritization. The fitted models were satisfactory for both groups with a slightly better fit for AHP compared to HHP (84.4% certainty fit versus 83.6%). Human-related criteria were more influential for HHP in their decision to prioritize zoonoses, while animal-related criteria were more influential for AHP resulting in different disease priority lists. While the differences were not statistically significant, a difference of one or two ranks could be considered important for some individuals. A potential solution to address the varying opinions is discussed. The scientific framework for disease prioritization presented can be revised on a regular basis by updating disease criteria to reflect diseases as they evolve over time; such a framework is of value allowing diseases of highest impact to be identified routinely for resource allocation.

Abstract OT1-03-06: LORELEI: A phase II randomized, double-blind study of neoadjuvant letrozole plus taselisib (GDC-0032) versus letrozole plus placebo in postmenopausal women with ER-positive/ HER2-negative, early-stage breast cancer

Background: Taselisib is an orally bioavailable, potent, selective inhibitor of Class I PI3-kinase (PI3K) alpha, gamma, and delta isoforms, with 30-fold less inhibition of the PI3K beta isoform relative to the alpha isoform showing enhanced activity against PIK3CA mutant cancer cell lines. Clinical data have demonstrated confirmed partial responses in patients with PIK3CA mutant breast cancer (BC) treated with single-agent taselisib. Enhanced antitumor activity has been noted when taselisib is combined with either letrozole or fulvestrant in preclinical and Phase Ib clinical studies.

Methods: LORELEI is a Phase II, two-arm, randomized, double-blind, multicenter, study of neoadjuvant letrozole and taselisib versus letrozole and placebo in postmenopausal women with newly diagnosed ER+/HER2-, untreated, Stage I-III operable BC. Other eligibility criteria include tumor size  2 cm by magnetic resonance imaging (MRI), ECOG PS 0-1, and evaluable tumor tissue for PIK3CA genotyping. Patients treated with anti-diabetic drugs are not eligible. Patients are randomized (1:1) to receive continuous letrozole (2.5 mg) with either taselisib (4 mg on a 5 days on/ 2 days off schedule) or placebo for 16 weeks, followed by surgery. Stratification is based on tumor size and nodal status. The co-primary endpoints are overall objective response rate (ORR) by centrally assessed breast MRI via modified RECIST criteria and pathologic complete response (pCR) rate in breast and axilla at time of surgery in all randomized patients and PIK3CA mutant patients. Secondary endpoints include ORR by centrally-assessed MRI and pCR rate in PIK3CA wild-type patients. The sample size was calculated to detect an absolute percentage increase of 24% in ORR with 80% power and an absolute percentage increase of 18% in pCR rate. An interim safety analysis will be conducted by an Independent Data Monitoring Committee. As of 1st Jun 2015, 54 of the 330 patients have been enrolled, and global enrollment is ongoing (clinicaltrials.gov NCT02273973).

Contact information:

Reference Study ID Numbers: GO28888/BIG-3-13/SOLTI 1205/ABCSG 38

Phone: 888-662-6728 (US Only)

Email Address: global.rochegenentechtrials@roche.com

Citation Format: Oliveira M, de Azambuja E, Saura C, Dubsky P, Zardavas D, Fesl C, Bardia A, Soberino J, Ciruelos Gil E, Ng V, Fredrickson J, Stout TJ, Singel SM, Hsu JY, Piccart M, Gnant M, Baselga J. LORELEI: A phase II randomized, double-blind study of neoadjuvant letrozole plus taselisib (GDC-0032) versus letrozole plus placebo in postmenopausal women with ER-positive/ HER2-negative, early-stage breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-03-06.

The genetic diversity of Epstein-Barr virus in the setting of transplantation relative to non-transplant settings: A feasibility study

This study examines EBV strains from transplant patients and patients with IM by sequencing major EBV genes. We also used NGS to detect EBV DNA within total genomic DNA, and to evaluate its genetic variation. Sanger sequencing of major EBV genes was used to compare SNVs from samples taken from transplant patients vs. patients with IM. We sequenced EBV DNA from a healthy EBV-seropositive individual on a HiSeq 2000 instrument. Data were mapped to the EBV reference genomes (AG876 and B95-8). The number of EBNA2 SNVs was higher than for EBNA1 and the other genes sequenced within comparable reference coordinates. For EBNA2, there was a median of 15 SNV among transplant samples compared with 10 among IM samples (p = 0.036). EBNA1 showed little variation between samples. For NGS, we identified 640 and 892 variants at an unadjusted p value of 5 × 10(-8) for AG876 and B95-8 genomes, respectively. We used complementary sequence strategies to examine EBV genetic diversity and its application to transplantation. The results provide the framework for further characterization of EBV strains and related outcomes after organ transplantation.

High Risk of Graft Failure in Emerging Adult Heart Transplant Recipients

Emerging adulthood (17-24 years) is a period of high risk for graft failure in kidney transplant. Whether a similar association exists in heart transplant recipients is unknown. We sought to estimate the relative hazards of graft failure at different current ages, compared with patients between 20 and 24 years old. We evaluated 11 473 patients recorded in the Scientific Registry of Transplant Recipients who received a first transplant at <40 years old (1988-2013) and had at least 6 months of graft function. Time-dependent Cox models were used to estimate the association between current age (time-dependent) and failure risk, adjusted for time since transplant and other potential confounders. Failure was defined as death following graft failure or retransplant; observation was censored at death with graft function. There were 2567 failures. Crude age-specific graft failure rates were highest in 21-24 year olds (4.2 per 100 person-years). Compared to individuals with the same time since transplant, 21-24 year olds had significantly higher failure rates than all other age periods except 17-20 years (HR 0.92 [95%CI 0.77, 1.09]) and 25-29 years (0.86 [0.73, 1.03]). Among young first heart transplant recipients, graft failure risks are highest in the period from 17 to 29 years of age.