Complicated Course Research Articles

Treatment of Esophageal Atresia in Germany: Analysis of National Hospital Discharge Data From 2016 to 2022

BackgroundEsophageal atresia (EA) is a complex malformation. Multidisciplinary management is necessary, with the operative repair being the most challenging step in the treatment algorithm. The complete care structure for children with EA in Germany has not been analyzed yet. MethodsIn the observed period 2016–2022, inpatient EA cases were analyzed 1) during the hospital stay of birth, and 2) during the hospital stay of corrective surgery in patients aged up to 365 days, both based on national hospital discharge data. Patients’ comorbidities, hospital caseload, treatment characteristics (e.g. surgical approach) and outcome parameters were analyzed. Results1) 1190 newborn EA cases were treated in 260 hospitals during the perinatal period. 54% had at least one additional malformation, and 16% had a birthweight below 1500 g. In-hospital mortality was 8.4%.2) 1475 corrective operations for EA were performed in 111 hospitals with a consistent median annual caseload of 2 (P25–P95 1–8) per hospital. At least one indicator for a complicated perioperative course was documented in 63.7% of cases. The use of bronchoscopy was coded in 50% of cases. Median ventilation time during the entire hospital stay was 176 h (P25–P95: 95–1759 h). ConclusionsNewborns with EA are complex and early postoperative complications are common. The care structure is decentralized, and there was no trend towards centralization in the observed period. The low documented use of bronchoscopy is noteworthy. Centralization of the highly complex and schedulable corrective surgery for EA is necessary to evaluate outcomes and might improve the quality of care and resource utilization. Category of the manuscript and type of studyoriginal article, observational cross-sectional study, secondary data analysis.

Developing a nomogram for predicting acute complicated course in pediatric acute hematogenous osteomyelitis

BackgroundThe objective of this study was to develop and validate a nomogram for predicting the risk of an acute complicated course in pediatric patients with Acute Hematogenous Osteomyelitis (AHO).MethodsA predictive model was developed based on a dataset of 82 pediatric AHO patients. Clinical data, imaging findings, and laboratory results were systematically collected for all patients. Subsequently, biomarker indices were calculated based on the laboratory results to facilitate a comprehensive evaluation. Univariate and multivariate logistic regression analyses were conducted to identify factors influencing early adverse outcomes in AHO. A nomogram model was constructed based on independent factors and validated internally through bootstrap methods. The discriminative ability, calibration, and clinical utility of the nomogram model were assessed using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA), respectively. The developed nomogram model was compared with previously published A-score and Gouveia scoring systems.ResultsLogistic regression analysis identified delayed source control, suppurative arthritis, albumin on admission, and platelet to lymphocyte ratio (PLR) as independent predictors of early adverse outcomes in pediatric AHO patients. The logistic regression model was formulated as: Log(P) = 7. 667–1.752 × delayed source control − 1.956 × suppurative arthritis − 0.154 × albumin on admission + 0.009 × PLR. The nomogram’s AUC obtained through Bootstrap validation was 0.829 (95% CI: 0.740–0.918). Calibration plots showed good agreement between predictions and observations. Decision curve analysis demonstrated that the model achieved net benefits across all threshold probabilities. The predictive efficacy of our nomogram model for acute complicated course in pediatric AHO patients surpassed that of the A-score and Gouveia scores.ConclusionsA predictive model for the acute complicated course of pediatric AHO was established based on four variables: delayed source control, suppurative arthritis, albumin on admission, and PLR. This model is practical, easy to use for clinicians, and can aid in guiding clinical treatment decisions.

Does computed tomography-derived volumometry and densitometry of psoas muscle really correlate with complications in rectal cancer patients after elective surgery?

Although sarcopenia is recognized as one of the risk factors for increased morbidity after resection for colorectal cancer, the question of the most appropriate way to identify and quantify it is still unresolved. This is a retrospective unicentric study following patients undergoing elective resection of the rectum for carcinoma with available staging computed tomography (CT) of the trunk. Psoas muscle density (PMD) and its area relative to patient height psoas muscle index (PMI) at the level of inferior vertebral end plate of third lumbar vertebra (L3) were assessed using an initial staging CT scan of the trunk. Post-operative complications, evaluated according to the Clavien-Dindo classification, and blood samples on post-operative days (POD) 3 and 5 were also recorded in the study population. Patients were divided into groups with complicated and uncomplicated post-operative course, and observed parameters were then statistically compared. The correlation of PMI values with the development of post-operative complications was not confirmed in a data set of 206 patients. PMD values were found to be borderline statistically significant in patients with complicated post-operative course, while in the group of patients with severe complications (Clavien-Dindo III-IV), there was no statistically significant difference in PMI or PMD values. The same results were obtained when comparing patients with anastomotic leak (AL). It was confirmed that operations on the lower rectum are riskier for the development of post-operative complications. The secondary objective of our study regarding serum C-reactive protein (CRP) levels of 3rd and 5th POD gave us the answer in the form of cutoff values of 115.7 mg/L (3rd POD) and 76 mg/L (5th POD). PMD appears to be a promising tool for predicting post-operative morbidity in patients after rectal resection, but a clear consensus on the method of measurement, interpretation of results and cutoff values is needed. Lower rectal resections are burdened with a higher risk of post-operative complications, especially AL. Monitoring of CRP levels remains an important marker in the prediction of AL due to its negative predictive value.

Frequency and clinical significance of Herpes simplex virus type 1/2 reactivation in adult patients with mild to moderately severe community-acquired pneumonia: a multicentre cohort study.

This study assessed the frequency, clinical significance, and risk factors for Herpes simplex virus (HSV) reactivation in immunocompetent patients with community-acquired pneumonia (CAP). The study included adult CAP-patients who were enrolled in the CAPNETZ study between 2007 and 2017 and had a residual sputum sample available for analysis. In addition to routine diagnostics, sputum and blood samples were tested for HSV-1/2 using PCR. Demographics, comorbidities, and CRB-65 score were compared between HSV-positive and negative patients using Fisher exact or Mann Whitney test. Logistic regression analyses investigated the influence of HSV reactivation on a modified hospital recovery scale (HRS) until day 7, divided into 3 categories (no oxygen therapy, oxygen therapy, ICU admission or death). Among 245 patients, HSV-1 and HSV-2 were detected in 30 patients (12.2%, 95%CI 8.7-16.9) and 0 patients, respectively. All HSV-positive patients were hospitalized, had a CRB-65 severity score of 0-2 and survived the first 28day. In the HSV-positive group, patients had a non-significantly higher median age (70.5 versus 66years) and a higher rate of oncological comorbidities (16.7% versus 8.8%) compared to the HSV-negative group. Distribution of co-pathogens and outcome parameters did not significantly differ between both groups. In a multivariate logistic regression model, age (AOR 1.029, p = 0.012) and CRB-65 score (AOR 1.709, p = 0.048), but not HSV-1 as single or co-pathogen were independently associated with higher HRS. Our study suggests that HSV-1 reactivation is common in CAP but might not be associated with specific risk factors or a complicated disease course.

Thalidomide as an adjunctive therapy in complex childhood neuro-tuberculosis: a case report

BackgroundTuberculosis remains a global health challenge, with central nervous system tuberculosis (CNSTB) affecting 5–10% of extrapulmonary tuberculosis cases, leading to severe complications in children aged 2 to 4 years. Despite timely diagnosis and intervention, management of CNSTB is a challenge. Thalidomide, a TNF-α inhibitor, is a potential therapeutic option in cases resistant to adjuvant corticosteroid therapy. This case report describes the management of complicated CNSTB utilising thalidomide, a less commonly used drug, with a favourable outcome.Clinical presentationA 3-year-old boy diagnosed with CNSTB and having a ventriculoperitoneal shunt presented with left-sided hemiparesis. He was previously diagnosed with tubercular meningitis at 2.5 years of age. On anti-tubercular treatment and corticosteroid, he had a complicated course with drug-induced liver injury (DILI) and paradoxical reaction. Despite a year of anti-tubercular therapy, there was a deterioration in neurological symptoms, accompanied by an increase in the number of tuberculomas observed on MRI. Adjuvant treatment with thalidomide proved effective in suppressing immunological activation, leading to a reduction in tuberculomas.ConclusionThis case highlights the intricacies of CNSTB, including complications and refractory tuberculomas. Thalidomide was effective in managing these challenges, offering a potential therapeutic option in challenging CNSTB cases. Positive clinical and radiological responses underscore the need to further explore thalidomide as an adjunctive therapy in similar paediatric cases.

Identification and transcriptomic assessment of latent profile pediatric septic shock phenotypes

BackgroundSepsis poses a grave threat, especially among children, but treatments are limited owing to heterogeneity among patients. We sought to test the clinical and biological relevance of pediatric septic shock subclasses identified using reproducible approaches.MethodsWe performed latent profile analyses using clinical, laboratory, and biomarker data from a prospective multi-center pediatric septic shock observational cohort to derive phenotypes and trained a support vector machine model to assign phenotypes in an internal validation set. We established the clinical relevance of phenotypes and tested for their interaction with common sepsis treatments on patient outcomes. We conducted transcriptomic analyses to delineate phenotype-specific biology and inferred underlying cell subpopulations. Finally, we compared whether latent profile phenotypes overlapped with established gene-expression endotypes and compared survival among patients based on an integrated subclassification scheme.ResultsAmong 1071 pediatric septic shock patients requiring vasoactive support on day 1 included, we identified two phenotypes which we designated as Phenotype 1 (19.5%) and Phenotype 2 (80.5%). Membership in Phenotype 1 was associated with ~ fourfold adjusted odds of complicated course relative to Phenotype 2. Patients belonging to Phenotype 1 were characterized by relatively higher Angiopoietin-2/Tie-2 ratio, Angiopoietin-2, soluble thrombomodulin (sTM), interleukin 8 (IL-8), and intercellular adhesion molecule 1 (ICAM-1) and lower Tie-2 and Angiopoietin-1 concentrations compared to Phenotype 2. We did not identify significant interactions between phenotypes, common treatments, and clinical outcomes. Transcriptomic analysis revealed overexpression of genes implicated in the innate immune response and driven primarily by developing neutrophils among patients designated as Phenotype 1. There was no statistically significant overlap between established gene-expression endotypes, reflective of the host adaptive response, and the newly derived phenotypes, reflective of the host innate response including microvascular endothelial dysfunction. However, an integrated subclassification scheme demonstrated varying survival probabilities when comparing patient endophenotypes.ConclusionsOur research underscores the reproducibility of latent profile analyses to identify pediatric septic shock phenotypes with high prognostic relevance. Pending validation, an integrated subclassification scheme, reflective of the different facets of the host response, holds promise to inform targeted intervention among those critically ill.Graphical abstract

Extended Drug Resistant Typhoid Fever; A Case Report

Enteric fever is a potentially fatal multisystem illness caused primarily by Salmonella typhi and, to a lesser extent, by Para typhi A, B, and C. Decades of indiscriminate usage of Antibiotics has led to emergence of multiple resistant strains. Multi drug resistant strains against Salmonella typhi has made treatment options limited and costly. According to WHO an estimated 11–20 million people get sick from typhoid all over the world. In the year 2022 an outbreak of Enteric fever emerged in April and spread all over Pakistan. This created a great concern as the causative organism were mostly Multi drug resistant. We recently have documented a case of extended drug resistant (XDR) Enteric Fever with a complicated clinical course, responding only to Carbapenem (Meropenem/Imipenem). The purpose of reporting this case was to highlight the morbidity, cost and therapeutic challenges which are associated with severe XDR S. typhi infection in Pakistan

Extended Drug Resistant Typhoid Fever; A Case Report

Enteric fever is a potentially fatal multisystem illness caused primarily by Salmonella typhi and, to a lesser extent, by Para typhi A, B, and C. Decades of indiscriminate usage of Antibiotics has led to emergence of multiple resistant strains. Multi drug resistant strains against Salmonella typhi has made treatment options limited and costly. According to WHO an estimated 11–20 million people get sick from typhoid all over the world. In the year 2022 an outbreak of Enteric fever emerged in April and spread all over Pakistan. This created a great concern as the causative organism were mostly Multi drug resistant. We recently have documented a case of extended drug resistant (XDR) Enteric Fever with a complicated clinical course, responding only to Carbapenem (Meropenem/Imipenem). The purpose of reporting this case was to highlight the morbidity, cost and therapeutic challenges which are associated with severe XDR S. typhi infection in Pakistan

Extended Drug Resistant Typhoid Fever; A Case Report

Enteric fever is a potentially fatal multisystem illness caused primarily by Salmonella typhi and, to a lesser extent, by Para typhi A, B, and C. Decades of indiscriminate usage of Antibiotics has led to emergence of multiple resistant strains. Multi drug resistant strains against Salmonella typhi has made treatment options limited and costly. According to WHO an estimated 11–20 million people get sick from typhoid all over the world. In the year 2022 an outbreak of Enteric fever emerged in April and spread all over Pakistan. This created a great concern as the causative organism were mostly Multi drug resistant. We recently have documented a case of extended drug resistant (XDR) Enteric Fever with a complicated clinical course, responding only to Carbapenem (Meropenem/Imipenem). The purpose of reporting this case was to highlight the morbidity, cost and therapeutic challenges which are associated with severe XDR S. typhi infection in Pakistan

Novel biomarkers to identify complicated course of febrile neutropenia in hematological patients receiving intensive chemotherapy.

Febrile neutropenia (FN) is a common consequence of intensive chemotherapy in hematological patients. More than 90% of the patients with acute myeloid leukemia (AML) develop FN, and 5%-10% of them die from subsequent sepsis. FN is very common also in autologous stem cell transplant recipients, but the risk of death is lower than in AML patients. In this review, we discuss biomarkers that have been evaluated for diagnostic and prognostic purposes in hematological patients with FN. In general, novel biomarkers have provided little benefit over traditional inflammatory biomarkers, such as C-reactive protein and procalcitonin. The utility of most biomarkers in hematological patients with FN has been evaluated in only a few small studies. Although some of them appear promising, much more data is needed before they can be implemented in the clinical evaluation of FN patients. Currently, close patient follow-up is key to detect complicated course of FN and the need for further interventions such as intensive care unit admission. Scoring systems such as q-SOFA (Quick Sequential Organ Failure Assessment) or NEWS (National Early Warning Sign) combined with traditional and/or novel biomarkers may provide added value in the clinical evaluation of FN patients.

New Pro-inflammatory Cytokines in Children and Adolescents with Type 1 Diabetes Patients with Microvascular Complications

Abstract Background Type 1 diabetes mellitus has become a global health burden, and poor glycemic control, in combination with prolonged diabetes duration, leads to the early development of microvascular complications, including diabetic kidney disease, retinopathy, and neuropathy. Therefore, it is urgent to establish new biomarkers for the early identification of at-risk patients. Objectives To investigate the role of inflammatory proteins (human growth differentiation factor 15 and interleukin 29) in the course of microvascular complications and glycemic control in T1DM. Patients and Methods Our study included 40 children with T1DM (18 T1DM patients had microvascular complications and 22 T1DM patients were free of these complications; their ages ranged from 8 to 18 years); there was also another T1DM subgroup based on glycemic control (11 T1DM patients had controlled HbA1c < 7% and 29 patients had uncontrolled HbA1C > 7%). 40 children of the same age were selected as a control group. The diagnosis of TIDM was made based on the criteria of the International Society of Pediatric and Adolescent Diabetes (ISPAD) (2022). A detailed medical history was collected, including the age of onset of diabetes, disease duration, and symptoms of diabetic complications. In the study, GDF15 and IL29 values in serum blood were investigated using the ELISA method. Results The mean age was 14.05 years in the diabetic group and 13.25 years in the control group (P = 0.178). In the T1DM patient group, the GDF15 and IL29 values were found to be significantly higher than those in the control group (P = 0.041 and 0.013, respectively). In diabetic patients, GDF15 was significantly higher in the complicated T1DM group versus the uncomplicated group (P = 0.001). Furthermore, GDF15 levels were significantly higher in uncontrolled patients with HbA1C > 7% than in the control group with HbA1C < 7% (P = 0.004); however, no significant statistical differences in IL29 levels were found between diabetic patient subgroups (P > 0.05). Conclusion The data from this study showed that GDF15 has an impact on glycemic control and that the presence of microvascular complications in the course of T1DM is very possible, but IL29 does not appear to play a role in the course of microvascular complications.

Risk prediction of complicated course in patients undergoing major head and neck surgery with free flap reconstruction

The British Association of Oral and Maxillofacial Surgeons (BAOMS) Quality and Outcomes in Oral and Maxillofacial Surgery (QOMS) reconstructive audit aims to provide surgical teams with risk adjusted comparative performance data. The goal is to enable surgeons to optimise surgical pathways. Risk adjustment requires that data on appropriate predictive variables are collected. This study looked at variables predicting major complications and flap failure in a single institution with the aim of determining whether the QOMS dataset adequately captures the appropriate data points. A prospective database of head and neck flap procedures and associated postoperative complications has been maintained in the maxillofacial surgery department since August 2009 up to August 2022 (n=1327). A total of 25 putative risk variables were extracted from the health records for each patient. The outcomes of interest were total flap failure and major complications. Independent predictors of flap failure were recipient site (sinonasal/anterior skull base), previous major surgery, previous major surgery and radiotherapy, and flap selection. For major complications ACE-27 comorbidity score, flap type, use of tracheostomy, elevated preoperative plasma C-reactive protein (CRP) and flap selection were independently predictive. Apart from preoperative activated innate immunity all relevant risk stratification variables identified in this study form part of the QOMS dataset. QOMS is therefore likely to adequately risk stratify patients based upon currently collected variables.

Regional Lymphadenitis Related to Bacille Calmette–Guerin Vaccination: A Case Series from a Tertiary Care Childrens’ Hospital

Background: Immunization with Bacille Calmette–Guerin (BCG) vaccine, used worldwide for years, for the prevention of tuberculosis, rarely leads to complications like regional lymphadenitis. There is controversy regarding the management of BCG lymphadenitis. We share our experience regarding the management and course of this rare complication in nine infants. Clinical Description: Over a period of 24 months, 9 infants, who had received BCG vaccination after birth, presented to us between 1 and 3 months of age, with left-sided supraclavicular swellings. The infants were otherwise thriving well, with no constitutional symptoms. On examination, the infants were stable with normal systemic examination. Local examination revealed all the swellings to be supraclavicular lymphadenopathies, two of them being suppurative. Thus, the infants fulfilled the clinical criteria for BCG regional lymphadenitis. Management and Outcome: Fine-needle aspiration cytology from the swellings of all infants was consistent with BCG lymphadenitis. Two of the smears were positive for acid-fast bacilli. Besides percutaneous pus aspiration in two infants, no other intervention was done in any of the infants, and no antibiotics nor antitubercular treatment was administered. With observation and regular follow-up, the lymphadenopathies resolved over time in all the infants. Conclusion: This case series creates awareness regarding the benign, self-resolving nature of BCG regional lymphadenitis, which may be followed conservatively without any medical or surgical intervention.

New Horizons in Diabetic Neuropathies: An Updated Review on their Pathology, Diagnosis, Mechanism, Screening Techniques, Pharmacological, and Future Approaches.

One of the largest problems for global public health is diabetes mellitus (DM) and its micro and macrovascular consequences. Although prevention, diagnosis, and treatment have generally improved, its incidence is predicted to keep rising over the coming years. Due to the intricacy of the molecular mechanisms, which include inflammation, oxidative stress, and angiogenesis, among others, discovering treatments to stop or slow the course of diabetic complications is still a current unmet need. The pathogenesis and development of diabetic neuropathies may be explained by a wide variety of molecular pathways, hexosamine pathways, such as MAPK pathway, PARP pathway, oxidative stress pathway polyol (sorbitol) pathway, cyclooxygenase pathway, and lipoxygenase pathway. Although diabetic neuropathies can be treated symptomatically, there are limited options for treating the underlying cause. Various pathways and screening models involved in diabetic neuropathies are discussed, along with their possible outcomes. Moreover, both medicinal and non-medical approaches to therapy are also explored. This study highlights the probable involvement of several processes and pathways in the establishment of diabetic neuropathies and presents in-depth knowledge of new therapeutic approaches intended to stop, delay, or reverse different types of diabetic complications.

Hyponatremia as a Biochemical Marker of complicated appendicitis: A prospective analysis of factors predicting the complicated course of appendicitis

Objective: To evaluate the role of hyponatremia as a marker of complicated appendicitis. Study Design: A prospective case series was conducted. Place and Duration: The study was carried out at the Surgical Unit of IIMCT-Pakistan Railway Hospital, Rawalpindi over a 6 months period from 20th November 2022 to 20th May 2023. Methodology: Hyponatremia was defined as serum sodium level equal or less than 135 mEq/L. Gangrenous as well as perforated appendix on per-operative examination were considered as complicated appendicitis. Sociodemographic and disease related factors (including gender, age, presenting complaint and hyponatremia) were recorded among the study population and were compared among complicated and uncomplicated cases. Results: A total of 86 (N) patients were studied. The inferential analysis illustrated that gender, chief presenting complaint and postoperative complications had no association with complicated appendicitis. However significantly higher (p=0.002 at chi square value of 9.781) number of complicated appendicitis (CA) cases had hyponatremia preoperatively, when compared to the non-complicated appendicitis cases (NCA). Hyponatremia had an accuracy of 68.6% at predicting complicated appendicitis with a sensitivity of 54.3% and specificity of 78.4%. The receiver operator curve (ROC) of serum sodium level for identification of complicated appendicitis illustrated area under the curve (AUC) of 0.82 with a highly significant p-Value of <0.001 (at 95% CI of 0.734-0.907). Conclusion: Hyponatremia is associated with complicated appendicitis. However, the sensitivity isn’t high enough for its use to rule out the complicated form. Keywords: Appendicitis, Hyponatremia, Perforation, Gangrene, Phlegmon, Peritonitis.

MICROBIOLOGICAL SPECTRUM OF INFECTIVE ENDOCARDITIS COMPLICATED BY HEART FAILURE

Resume. Infective endocarditis (IE) is a serious disease that can lead to severe complications and death. The study of the microbiological spectrum of pathogens in such patients is great importance for optimizing treatment and increasing the effectiveness treatment. The spectrum of IE pathogens has changed significantly over the past decades. A positive microbiological blood test remains the cornerstone in diagnosis and etiotropic antimicrobial therapy of IE. Considering the global mobility of the population and the growing resistance of microorganisms to antibiotics, it is necessary to update our knowledge about the microbiological spectrum of infective endocarditis constantly. THE AIM was to investigate the microbiological spectrum of pathogens in patients with infective endocarditis complicated by heart failure. Materials and methods. Clinical data of 120 patients with active infective endocarditis who underwent treatment at the SE «Amosov National Institute of Cardiovascular Surgery» National Academy of Medical Sciences of Ukraine from 01.01.2019 to 06.30.2020 were enrolled in the study. The diagnosis of IE was established in accordance with Duke's criteria. The average age of the studied patients was 48.1±1.37 (19-77) years. Results. The rate of gram-positive and gramnegative microorganisms was 69 (93.2 %) cases and 5 (6.8 %) cases respectively. Gram-positive microorganisms were found – Staphylococcus spp. in 42 (56.8 %) cases and Enterococcus spp. in 20 (27.0 %) cases. A high level of oxacillin-resistant (p=0.072) and vancomycin-resistant (p=0.027) strains of microorganisms were found in the group of patients with preoperative heart failure. Conclusions: The microbiological spectrum of IE pathogens in patients with heart failure is characterized by the predominance of gram-positive strains that are resistant to oxacillin and vancomycin. Positive results of bacteriologic blood tests were found in 74 cases out of the total number, which is 61.7 %. Of these, gram-positive microorganisms were detected in 69 cases (93.2 %), while gram-negative microorganisms were detected in only 5 cases (6.8 %). The most common gram-positive microorganisms were Staphylococcus spp. (56.8 %) and Enterococcus spp. (27.0%). There was also found that risk factors such as nosocomial infections, hypothermia and drug abuse can contribute to the development of UI. The overall frequency of nosocomial factors in the development of the disease was 36.7 %. Urological interventions (12.5 %) and general surgical interventions (20.8 %) were among the most common. Our study included patients with active UI who had positive bacteriologic blood tests and signs of a systemic inflammatory response. In these patients, the mean body temperature at hospitalization was 38.3 °C, and the mean heart rate was 91.0 beats/min. The organ dysfunction detected in patients with complicated IE was also confirmed by high levels of creatinine (168.2 mcg/L) and urea (13.3 mmol/L). A comparative analysis of laboratory results also revealed a high level of resistant strains of microorganisms in the group of patients with complicated IE. Thus, the data obtained confirm the seriousness of the problem of infective endocarditis and emphasize the need for further research to develop effective strategies for the diagnosis and treatment of this disease, especially in patients with complicated course.

The role of preoperative D-dimer blood level in assessing the risk of open abdominal aortic surgery (statistical study)

Introduction. Changes in the hemostasis and fibrinolysis system in patients with aortoiliac segment lesion can cause the development of specific thromboembolic and hemorrhagic complications, accompanied by a high level of mortality. Preoperative laboratory analysis of the D-dimer blood level may help to objectify the risk assessment of open surgery in this category of patients. Objective. Assessment of the significance of preoperative blood D-dimer level in predicting the development of morbidity and mortality after open surgery on the aortoiliac segment. Materials and methods. The study included 108 patients who were determined the D-dimer blood level before planned reconstructive intervention on the aortoiliac segment at the Pavlov University from 2013 to 2021. The first group consisted of 56 patients with aneurysmal aortoiliac segment lesions, and the second group included 52 patients with occlusive-stenotic lesions of the aortoiliac segment. Results. 92 (85%) patients had an increase of D-dimer level above 500 μg/L, among them 18 patients developed early postoperative complications, and 4 cases were fatal. In 16 (15%) patients with normal D-dimer levels, the postoperative the period was uneventful. Both groups showed statistically significant differences in preoperative blood D-dimer levels depending on the presence or absence of early postoperative complications. In the first group, the median of D-dimer level in the smooth course of the postoperative period was 2035 μg/L, and in patients with complicated course – 3770 μg/L (p=0.04), in the second group these indicators were 635 μg/L and 1231.5 μg/L (p=0.02), respectively. The threshold value of D-dimer level in predicting the risk of death in the first group was 4150 μg/L (p=0.001). Conclusion. The blood D-dimer level may be an additional laboratory risk factor for adverse outcome of open surgery in patients with aortoiliac occlusive disease.

Методологія профілактики великих акушерських синдромів

Aim - to develop a method of prevention of major obstetric syndromes (MOS) from the standpoint of a single genesis determined by morphofunctional disorders in the fetoplacental system (FPS), with an assessment of effectiveness by methodological standards of evidence-based medicine Materials and methods. The group I - 32 pregnant women, prevention of MOS was carried out with low doses of acetylsalicylic acid (ASA) at 100-150 mg per os once a day, from 12 to 36 weeks of pregnancy; the group II - 31 pregnant women, who from 6 to 16 weeks were treated prophylactically with progesterone according to the scheme: 200 mg 1 time per day per vagina every day; the group III - 36 pregnant women who received prophylactic monotherapy, consisting of taking magnesium in combination with vitamin B6 for three courses of 6 weeks each; the group IV - 56 pregnant women who refused any preventive measures; the control group (CG) - 50 healthy pregnant women. Тhe effectiveness of prophylactic therapy was evaluated by dynamic examination of the pregnant groups of the study, which included the determination of the following indicators: placental alpha microglobulin (PAMG); placental growth factor; placental protein (PAPP-A), blood leukocyte elevation index, allergy index, concentration of magnesium in blood serum. To objectify the effectiveness of the developed method, the standards of evidence-based medicine were applied. Statistical processing of research results was carried out using standard Microsoft Excel 5.0 and Statistical 6.0 programs. Results. In pregnant women of the group IV, the level of the fibronectin (521±17 μg/ml) increased by an average of 17%, compared to patients of the groups I-III (355±12 μg/ml, 361±13 μg/ml, 368±16 μg/ml; p<0.05), which led to a subsequent increase in the frequency of spontaneous premature births in patients of the group IV; the level of PAMG exceeds the value in the CG by 7.7 times in the group IV; in the group III by 1.7 times, and in pregnant women of groups I and II, it was 25.2±3.8 ng/ml and 26.4±4.2 ng/ml, respectively, against 177±18 ng/ml in group IV (p<0.05). The concentration of the PAPP-A was reduced from the early stages of pregnancy in all studied groups - 6.9±1.8 mg/l, 8.8±1.9 mg/l, 9.2±2.1 mg/l, 7.5±1.6 mg/l (according to the groups I-IV) versus 15.7±2.5 mg/l in the CG (р<0.05). When using the magnesium drug (III group), there are differences with the group IV in most indicators. Conclusions. Methods for the prevention of a complicated course in the high-risk groups for the development of vasculitis when studying personalized and predictive value, which made it possible to divide them in order from more effective to less effective: the method with the appointment of low doses of ASA was in the first place; on the II - prophylactic appointment of micronized vaginal progesterone; on the III - the use of magnesium. The research was conducted according to principles of Declaration of Helsinki. Protocol of research was proved by local ethical committee, mentioned in institution’s work. A informed sonsennt was collected in order to carry out the research. The author is stating no conflict of interests is declared.

MIS-C Treatment: Is glucocorticoid monotherapy enough for mild cases?

BackgroundThe effectiveness of using only glucocorticoids (GCs) in mild multisystem inflammatory syndrome (MIS-C) cases was compared with combined treatment [GCs + Intravenous immune globulin (IVIG)]. MethodsThis retrospective cohort study was conducted between June 1, 2020, and June 1, 2022, in a tertiary care center in Istanbul, Turkey. Clinical and investigational data of the MIS-C patients were analyzed. The patients were divided into two groups: those who received only GCs and those who received the GCs + IVIG combination. The primary outcome focused on assessing the deterioration of the patient's clinical condition, the occurrence of shock, admission to the pediatric intensive care unit (PICU), and the need for additional immunosuppressive medication. Secondary outcomes included evaluating the course of cardiovascular and infection-related complications observed at the one-year follow-up. ResultsNinety-seven MIS-C patients with a median age of 41 (3‐ 214) months were enrolled. Fifty-six (57.7%) patients were male. All the patients had fever at admission with a temperature of 39 °C (37.5 °C–40.1 °C). Thirty-two patients (33%) had cardiac findings on echocardiography [left ventricular dysfunction (n= 13, 13.5%), coronary artery involvement (n= 11, 11.3%), and dilation of cardiac cavities and/or increased cardiac muscle thickness (n= 8, 8.2%)]. Thirteen patients (13.5%) required intensive care. All patients received GCs [only GCs (group I; n= 65, 67%)], and 32 patients (33%) with severe manifestations and/or cardiac involvement received GCs + IVIG (group II). No mortality was observed. None of the patients had any complaints at the one-year follow-up, and all echocardiography findings were normal. ConclusionThis study provides preliminary evidence that GC monotherapy is a safe treatment alternative for mild MIS-C cases without cardiac involvement.

Prevalence and early surgical outcome of congenital diaphragmatic hernia in the Netherlands: a population-based cohort study from the European Pediatric Surgical Audit

BackgroundCongenital diaphragmatic hernia (CDH) is a rare birth defect with substantial mortality. This study aims to generate a population-based overview of CDH care and outcomes in the Netherlands. Moreover, it...