Concurrent Aspiration Research Articles

ESRD IN PATIENTS WITH IBD: AN ANALYSIS OF THE NATIONAL INPATIENT SAMPLE 2015-2019

Abstract BACKGROUND Inflammatory Bowel Disease (IBD) can have numerous complications involving all systems of the body. There are limited data investigating the effect of renal disease on outcomes in patients with IBD . The aim of our study was to examine the impact of End-Stage Renal Disease (ESRD) on the outcomes of patients with IBD. METHODS The Nationwide Inpatient Sample (NIS) database encompasses approximately 7 million inpatient hospitalizations annually in the United States. Data were extracted from the National Inpatient Sample (NIS) Database for the years 2015-2019. Patients aged 18 years and above with diagnoses of IBD and ESRD were identified using ICD codes. Multivariate regression analysis was used to estimate the odds ratios of in-hospital mortality, the average length of hospital stay (LOS), and hospital charges using STATA 17. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders. RESULTS We identified 226,264 patients with IBD of which 44,340 patients were matched to those with diagnoses of ESRD. Average age was 60.4 years. There was a significant increase in inpatient mortality (OR 2.22, CI 1.629486-3.018497, p<0.0001), total cost of hospitalization ($31,461.41, CI 21,365.89 - 41,556.94, p<0.0001), and hospital length of stay (2.03 days, CI 1.392255-2.674399, p<0.0001) in patients with IBD with a concurrent diagnosis of ESRD when compared to IBD patients without ESRD. On multivariate analysis, positive predictors of mortality were sepsis (OR: 6.828519 p-value: <0.001; 95% CI: 5.809829 8.025826), aspiration events,(OR: 3.78247 p-value: <0.001; 95% CI: 2.939117- 4.867815), and malnourishment (OR: 2.919507 p-value: <0.001; 95% CI: 2.447496- 3.482547). LOS was increased in patients with hospitalizations complicated by sepsis (OR 3.282481; p-value: <0.001; 95% CI: 2.96-3.60), malnutrition (OR 5.60; p-value: <0.001; CI: 5.11- 6.08), and aspiration events (OR 3.58; p-value:<0.001;CI: 2.74-4.42). Total hospital charges were increased in patients with hospitalizations complicated by sepsis ( $45,351.03; p-value: <0.001; 95% CI: 39,370.62-51,331.44), malnutrition ($63,326.1; p-value: <0.001; CI: 52,921.92-73,730.27), and aspiration events($ 57,778.34; p-value: <0.001; CI: 40,777.18-74,779.5). CONCLUSIONS Our study demonstrates the presence of ESRD in hospitalized patients with IBD is associated with poor outcomes in terms of mortality, length of stay, and total hospital charges. Furthermore concurrent aspiration events, malnutrition, and sepsis are also associated with worsened outcomes. Our study is novel because there are minimal data that investigate the clinical outcomes associated with IBD patients with ESRD. Our study demonstrates that the presence of ESRD poses a significant mortality risk in these patients, among other factors.

Use of Negative Pressure Ventilation in Pediatric Critical Care: Experience in 56 PICUs in the Virtual Pediatric Systems Database (2009-2019).

Negative pressure ventilation may be more physiologic than positive pressure ventilation, but data describing negative pressure ventilation use in the PICU are limited. We aimed to describe the epidemiology and outcomes of PICU patients receiving negative pressure ventilation. Descriptive analysis of a large, quality-controlled multicenter database. Fifty-six PICUs in the Virtual Pediatric Systems database who reported use of negative pressure ventilation. Children admitted to a participating PICU between 2009 and 2019 who received negative pressure ventilation. None. Among 788 subjects, 71% were less than 2 years old, and 45% had underlying health conditions. Two concurrent aspiration events were the only adverse events reported. After excluding one over-represented center, the 3 years with the most negative pressure ventilation usage were 2017-2019 (all > 25 cases/yr and ≥ 13 centers reporting usage). Among those 187 children, the most common primary diagnoses were bronchiolitis and cardiac disease (both 15.5%), 24.1% required endotracheal intubation after negative pressure ventilation, and 9.1% died. Negative pressure ventilation is being used in many PICUs, most commonly for pulmonary infections or cardiac disease, in children with high rates of subsequent intubation and mortality and with few documented adverse events. Use at individual centers is rare but increasing, suggesting need for prospective collaboration to better evaluate the role of negative pressure ventilation in the PICU.

Prospective Evaluation of Adequacy of Bone Marrow Biopsies Comparing Standard Jamshidi Needle to the OnControl Power Driver and Bone Marrow Biopsy System

AbstractAbstract 4739 BACKGROUND:Evaluation of the bone marrow is a routine part of staging of many hematologic malignancies including lymphoma. Bishop et al. (J. Clin. Path. 1992:45;1105) determined that there was a relationship between the length of a trephine biopsy and the likelihood of identifying tumor in the specimen. They found that the yield of malignancy reached a plateau when specimens were greater than or equal to 1.6 cm length, prior to fixation. In a yearlong audit of the results from Christie Hospital 58% of trephine biopsies were found to be inadequate based on this criterion. Though there have been improvements to trephine needles for bone marrow biopsy they all require manual insertion of the needle into the bone to obtain a core. Furthermore, significant variation has been reported among individuals performing trephine biopsies with respect to adequacy of resulting sample. OnControl has introduced a bone marrow biopsy system that uses a power driver to assist in the insertion of the needle into the marrow. In the fall of 2009, 9 physicians were trained on the system. Over the next six months, physicians could choose at their discretion to use a disposable Jamshidi needle with a crown tip or the OnControl bone marrow biopsy system. The results were recorded in a registry as part of a hospital Quality Assurance Project. METHODS:A prospective registry recorded the date of the procedure, operator, needle type, length of the specimen as determine by pathology, overall cellularity, and involvement of the specimen by tumor. Complications, if any, were to be recorded. For the manual procedures, concurrent aspirate were obtained with an Illinois needle at an adjacent site. With the OnControl system the aspirate and biopsy were performed sequential through a single bone marrow puncture. RESULTS:From January to July, 2010, 142 bone marrow biopsies were performed by the attendings on the Lymphoma Service, 77 with a Jamshidi needle and 65 with the OnControl system. Length: The median lengths were 12mm (0-26) with the Jamshidi and 18mm (6-32) with the OnControl system (p<0.001). The median biopsy length among individual operators ranged from 6 to 15 mm and 11 to 21 mm for the Jamshidi and OnControl system, respectively. Cellularity: For marrow specimens uninvolved by lymphoma, the median cellularity was not different between the two methods; 40% with the Jamshidi (N=59) and 45% with the OnControl (N=45) (p=0.575). Safety: There were no reported procedures-related complications reported with either technique. In three cases, there was some difficulty in removing the marrow core from the OnControl needle (4.6%). Biopsy Adequacy: Using the data driven length of 16mm for adequacy, only 42% of all bone marrows were of an adequate length. However, 60% of the biopsies from the OnControl system were ≥ 16mm compared to 27% of the biopsies obtained with the traditional Jamshidi needle (p<0.001). CONCLUSIONS:The OnContol bone marrow biopsy system resulted is a significantly higher proportion of adequate trephine biopsies avoiding the need for repeat or bilateral procedures. The sequential aspirate and biopsy through a single needle did not result in focal hypocellularity of the marrow. The OnControl bone marrow biopsy system is safe and a more effective alternative to conventional Jamshidi biopsy needle. Disclosures:Zelenetz:Communicore: Honoraria.

Nonsurgical Treatment of Gastroesophageal Intussusception in a Puppy

A 7-week-old, female Siberian husky was presented to Murdoch University Veterinary Hospital with an acute onset of respiratory distress and regurgitation. Thoracic imaging identified an intraluminal esophageal mass with concurrent aspiration pneumonia. Esophagoscopy identified the mass as stomach, and a diagnosis of gastroesophageal intussusception was made. The intussusception was reduced endoscopically, and fixation of the stomach to the abdominal wall was performed using a tube gastropexy. Gastroesophageal intussusception is an uncommon disease in small animals and traditionally has been managed surgically. This case report describes an alternative method of treatment associated with a good outcome in this puppy.

Cytomegalovirus Colitis in an HIV‐Positive Woman with a Relatively Preserved CD4 Count

To the Editor: Cytomegalovirus (CMV) disease typically occurs in immunocompromised individuals including HIV-positive patients with CD4 counts less than 50 cells/μL to 100 cells/μL (1). There have been few cases of CMV gastrointestinal disease reported in patients with CD4 counts greater than 50 cells/μL to 100 cells/μL (2,3). We describe a case of CMV colitis in an HIV-infected patient with a relatively preserved CD4 count. A 39-year-old woman with known HIV infection, hepatitis C virus infection, alcoholism and injection drug use was admitted to hospital in August 2006 with a decreased level of consciousness secondary to an overdose of methadone. Acutely, her methadone overdose was treated with supportive care, and she received therapy for concurrent aspiration pneumonia. Once alert, she complained of dysphagia, epigastric pain and nonlocalizing lower abdominal pain. She appeared wasted and described weight loss over the preceding year for which she had not sought medical care. She attributed her weight loss to poor oral intake and chronic watery diarrhea but denied fevers or night sweats. She had never maintained consistent follow-up for her HIV infection and other comorbidities due to a transient lifestyle. She had no known history of opportunistic infections and had never received antiretroviral therapy. Her CD4 count at the time of hospitalization was 340 cells/μL (34%). Investigations revealed endoscopically and microbiologically documented Candida esophagitis. Biopsies of the duodenum and small bowel revealed mild inflammation without evidence of mycobacterial disease or CMV on histopathology. Colonoscopy revealed diffuse inflammation and mucosal ulceration, but the histopathology was nondiagnostic. Specifically, there was no evidence of CMV colitis. Mycobacterial and fungal cultures of the colon were also negative. Stool samples were negative for Clostridium difficile toxin, pathogenic bacteria and parasites including Microsporidia, Isospora, Cryptosporidia and Cyclospora. There was no clinical, laboratory or radiographic evidence of cirrhosis, and sputum and blood cultures for Mycobacterium species were negative. She received oral fluconazole for esophageal candidiasis and her dysphagia improved, although her anorexia and abdominal discomfort persisted. She was discharged and out-patient follow-up with Gastroenterology and Infectious Diseases was arranged. The patient missed her follow-up appointments and returned to hospital three weeks later with worsening abdominal pain and persistent anorexia. She had clinical evidence of peritonitis and radiological evidence of a perforated viscus. She was taken to the operating room where multiple small and large bowel perforations were found. She required a right hemicolectomy and underwent an abdominal wash-out. Pathology was consistent with CMV colitis with numerous CMV inclusion bodies identified throughout all biopsies of small and large bowel. Biopsy cultures were negative for mycobacteria and fungi. Repeat stool examinations were negative for Clostridium difficile toxin, pathogenic bacteria and parasites. A repeat CD4 count at this second admission was 270 cells/μL (34%), with an HIV viral load of 13,000 RNA copies/mL. Review of her CD4 counts over time confirmed that her CD4 count had never been below 270 cells/μL. She was treated with intravenous ganciclovir 5mg/kg twice daily for 20 days and improved. She was discharged with follow-up with a plan to begin highly active antiretroviral therapy as an outpatient. Two cases of HIV-infected patients with CMV colitis and relatively preserved CD4 counts in the setting of malnutrition and alcoholism have been described previously (2,3).Malnutrition has long been associated with anergy and impaired T cell function, thereby potentially predisposing patients to reactivation of CMV (4). Indeed, there are case reports of CMV disease in malnourished individuals, who were otherwise apparently immunocompetent (5,6). The exact mechanism by which this would lead to enhanced CMV reactivation is unknown. Another commonality between our case and the two previous case reports was the presence of esophageal candidiasis. Yotsumoto et al (2) hypothesized that candidiasis may damage the mucosa leading to impairment of the local immunological defense system resulting in local CMV disease. It is clinically important not to miss the diagnosis of CMV colitis as effective treatment is available. Typically, patients are treated with either a course of intravenous ganciclovir or foscarnet, for 21 to 28 days (7). Secondary prophylaxis is not routinely recommended for gastrointestinal disease but should be considered if relapses occur (7). It should be noted that an episode of CMV colitis is evidence of symptomatic HIV infection and is thus an indication for initiation of highly active antiretroviral therapy (7). Although gastrointestinal manifestations of CMV in patients with advanced HIV disease are well described, our case highlights the fact that CMV colitis can also occur in patients with relatively preserved CD4 counts (ie, CD4 counts of 250 cells/μL to 350 cells/μL), and should be included in the differential diagnosis of any HIV-positive patient presenting with lower gastrointestinal symptoms, regardless of their CD4 counts. Significant alcohol use, malnutrition and Candida esophagitis may predispose to CMV colitis in HIV-positive patients.

Sonographically guided fine-needle biopsy of thyroid nodules: the effects of nodule characteristics, sampling technique, and needle size on the adequacy of cytological material

To evaluate the effects of sonographic characteristics of thyroid nodules, the diameter of needle used for sampling, and sampling technique on obtaining sufficient cytological material (SCM). We performed sonography-guided fine-needle biopsy (FNB) in 232 solid thyroid nodules. Size-, echogenicity, vascularity, and localization of all nodules were evaluated by Doppler sonography before the biopsy. Needles of size 20, 22, and 24 G were used for biopsy. The biopsy specimen was acquired using two different methods after localisation. In first method, the needle tip was advanced into the nodule in various positions using a to-and-fro motion whilst in the nodule, along with concurrent aspiration. In the second method, the needle was advanced vigorously using a to-and-fro motion within the nodule whilst being rotated on its axis (capillary-action technique). The mean nodule size was 2.1+/-1.3 cm (range 0.4-7.2 cm). SCM was acquired from 154 (66.4%) nodules by sonography-guided FNB. In 78 (33.6%) nodules, SCM could not be collected. There was no significant difference between nodules with different echogenicity and vascularity for SCM. Regarding the needle size, the lowest rate of SCM was obtained using 20 G needles (56.6%) and the highest rate of adequate material was obtained using 24 G needles (82.5%; p=0.001). The SCM rate was 76.9% with the capillary-action technique versus 49.4% with the aspiration technique (p<0.001). Selecting finer needles (24-25 G) for sonography-guided FNB of thyroid nodules and using the capillary-action technique decreased the rate of inadequate material in cytological examination.

Volatile metal and metalloid species in gases from municipal waste deposits

AbstractWe have detected volatile species of silicon, vanadium, arsenic, bromine, tin, antimony, tellurium, iodine, mercury, lead and bismuth in gases released from domestic waste deposits, using inductively coupled argon plasma mass spectrometry (ICP MS). By concurrent aspiration of a multielement standard solution for calibration, the element concentrations in deposit gas are found to be in the range from 0.1 ng m−3 to 10 μg m−3 gas. The global amount of some metal species emitted by this process may be of the order of several tons per year. These results suggest a biogeochemical pathway for the transfer of metals into the atmosphere via volatile species. This process may have significant influence on atmospheric cycling of metals as well as on metal toxicity within ecosystems.