High Risk For Surgical Intervention Research Articles

Refractory type 1 plastic bronchitis in a child; case report

BackgroundPlastic bronchitis (PB) is a rare pediatric pulmonary condition characterized by the production of branching bronchial casts that cause partial or total obstruction of the bronchial lumen.Case presentationWe describe a 13-year-old boy with a history of bronchial asthma and left lower lobectomy, with persistent cough and left-sided chest pain when he went to the emergency room. Chest radiography showed complete left lung opacity denoting total left lung collapse, and flexible bronchoscopy revealed cohesive casts totally occluding the left bronchus, with frequent recurrence that finally ended with left pneumonectomy.ConclusionPlastic bronchitis is a rare, fatal disease in children that requires a high index of suspicion for both diagnosis and treatment. Although bronchoscopic removal of the bronchial casts together with the medical treatment are the main lines of treatment, cases with recurrent formation of casts are at high risk for surgical intervention in the form of either lobectomy or pneumonectomy.

Safety and efficacy of percutaneous lead extraction of infected cardiac electronic devices: a single-center study

Abstract Funding Acknowledgements None. Background Infections of implanted cardiac electronic devices (CIEDs) are associated with increased morbidity and mortality. Current guidelines recommend either percutaneous or surgical lead removal. Purpose To assess and document the safety and efficacy of percutaneous lead extraction within our Electrophysiology (EP) Lab over the past 2 years. Methods We enrolled consecutive patients with CIED-related infections who underwent percutaneous lead extractions at our EP lab. Results A total of 26 consecutive patients were included in the study, of whom 21 (81%) were males, with a median age of 67 years. Among these patients, 9 (35%) had permanent pacemakers, 11 (42%) had implantable defibrillator systems, and 6 (23%) had biventricular defibrillator systems. Device extrusion was observed in 17 patients (65%), while the remaining 9 (35%) had lead vegetations. Among the 17 patients with device extrusion, 3 (18%) also had lead vegetations, but only 2 (12%) had positive blood cultures. Among the 9 patients without device extrusion, 5 (56%) had vegetations in the leads and tricuspid valve, while 4 (44%) had positive blood cultures. The mean duration from CIED implantation to infection was 81.5 months. Percutaneous lead extraction of CIEDs was successful in 25 patients (96%) using transvenous rotational dilators and endovascular lead extraction tools. In one patient, femoral access with a snare was required for lead retrieval. In another case, where complete lead removal was necessary, the patient developed a massive pulmonary embolism, leading to surgical removal. Additionally, in one patient with a 20-year-old permanent pacemaker, lead extraction was not successful; however, surgical removal was avoided due to the high risk involved. Conclusions The use of transvenous rotational dilators and endovascular lead extraction tools for transvenous removal of CIEDs due to extrusion and/or endocarditis is safe and highly effective, avoiding high-risk cardiac surgical interventions.

Machine learning-based analysis for prediction of surgical necrotizing enterocolitis in very low birth weight infants using perinatal factors: a nationwide cohort study.

Early prediction of surgical necrotizing enterocolitis (sNEC) in preterm infants is important. However, owing to the complexity of the disease, identifying infants with NEC at a high risk for surgical intervention is difficult. We developed a machine learning (ML) algorithm to predict sNEC using perinatal factors obtained from the national cohort registry of very low birth weight (VLBW) infants. Data were collected from the medical records of 16,385 VLBW infants registered in the Korean Neonatal Network (KNN). Infants who underwent surgical intervention were identified with sNEC, and infants who received medical treatment, with medical NEC (mNEC). We used 38 variables, including maternal, prenatal, and postnatal factors that were obtained within 1week of birth, for training. A total of 1085 patients had NEC (654 with sNEC and 431 with mNEC). VLBW infants showed a higher incidence of sNEC at a lower gestational age (GA) (p < 0.001). Our proposed ensemble model showed an area under the receiver operating characteristic curve of 0.721 for sNEC prediction. Conclusion: Proposed ensemble model may help predict which infants with NEC are likely to develop sNEC. Through early prediction and prompt intervention, prognosis of sNEC may be improved. What is Known: • Machine learning (ML)-based techniques have been employed in NEC research for prediction, diagnosis, and prognosis, with promising outcomes. • While most studies have utilized abdominal radiographs and clinical manifestations of NEC as data sources, and have demonstrated their usefulness, they may prove weak in terms of early prediction. What is New: • We analyzed the perinatal factors of VLBW infants acquired within 7 days of birth and used ML-based analysis to identify which infants with NEC are vulnerable to clinical deterioration and at high risk for surgical intervention using nationwide cohort data.

Deep learning-based identification of eyes at risk for glaucoma surgery

To develop and evaluate the performance of a deep learning model (DLM) that predicts eyes at high risk of surgical intervention for uncontrolled glaucoma based on multimodal data from an initial ophthalmology visit. Longitudinal, observational, retrospective study. 4898 unique eyes from 4038 adult glaucoma or glaucoma-suspect patients who underwent surgery for uncontrolled glaucoma (trabeculectomy, tube shunt, xen, or diode surgery) between 2013 and 2021, or did not undergo glaucoma surgery but had 3 or more ophthalmology visits. We constructed a DLM to predict the occurrence of glaucoma surgery within various time horizons from a baseline visit. Model inputs included spatially oriented visual field (VF) and optical coherence tomography (OCT) data as well as clinical and demographic features. Separate DLMs with the same architecture were trained to predict the occurrence of surgery within 3 months, within 3–6 months, within 6 months–1 year, within 1–2 years, within 2–3 years, within 3–4 years, and within 4–5 years from the baseline visit. Included eyes were randomly split into 60%, 20%, and 20% for training, validation, and testing. DLM performance was measured using area under the receiver operating characteristic curve (AUC) and precision-recall curve (PRC). Shapley additive explanations (SHAP) were utilized to assess the importance of different features. Model prediction of surgery for uncontrolled glaucoma within 3 months had the best AUC of 0.92 (95% CI 0.88, 0.96). DLMs achieved clinically useful AUC values (> 0.8) for all models that predicted the occurrence of surgery within 3 years. According to SHAP analysis, all 7 models placed intraocular pressure (IOP) within the five most important features in predicting the occurrence of glaucoma surgery. Mean deviation (MD) and average retinal nerve fiber layer (RNFL) thickness were listed among the top 5 most important features by 6 of the 7 models. DLMs can successfully identify eyes requiring surgery for uncontrolled glaucoma within specific time horizons. Predictive performance decreases as the time horizon for forecasting surgery increases. Implementing prediction models in a clinical setting may help identify patients that should be referred to a glaucoma specialist for surgical evaluation.

Clinical Investigation of Hereditary and Acquired Thrombophilic Factors in Patients with Venous and Arterial Thromboembolism.

The clinical relevance of thrombophilic laboratory factors, especially the "mild" ones, and the need for their screening is not generally recommended in venous (VTE) and/or arterial (ATE) thromboembolism. Our aim was to investigate possible associations between comorbidities and 16 inherited/acquired "severe" and "mild" laboratory thrombophilic factors (detailed in introduction) in patients (n=348) with VTE/ATE without a serious trigger (high-risk surgical intervention, active cancer and/or chemo-radiotherapy). Cases with VTE/ATE were enrolled when the thrombotic event occurred under the age of 40, in case of positive family history, recurrent thromboembolism, idiopathic event or unusual location. Patients without a detailed thrombophilia screening or who suffered from both ATE/VTE were excluded to find potential distinct thrombosis type specific thrombophilic risks. The possible role of "mild" factor accumulation was also investigated in VTE (n=266). Elevation of factor VIII clotting activity was associated with VTE rather than ATE. Varicose veins together with postthrombotic syndrome were strongly related to several "mild" factors. Besides "severe" we found that the "mild" thrombophilic factors were also strongly associated with VTE/ATE. Comorbidities/conditions such as diabetes and smoking were generally associated with hyperlipidemia; moreover, both had a correlation with lipoprotein (a) in VTE. We also revealed an important contribution of "mild" factors in increasing trends of several types and localizations of VTE. In summary, besides the "severe" thrombophilic factors, the "mild" ones also seem to play a non-negligible role in the manifestation of thrombosis, especially in combination. Therefore, an extended screening might be useful in the personalized recommendation of antithrombotic prophylaxis.

Bilateral cerebellopontine angle lipomas in an infant with encephalocele: illustrative case.

Bilateral cerebellopontine angle (CPA) lipomas are extremely rare. Herein the authors present a case of bilateral CPA lipomas in an infant along with a literature review of bilateral CPA lipomas. A newborn girl was incidentally found to have bilateral CPA lipomas during the workup for an occipital encephalocele. The encephalocele was repaired primarily on day 2 after birth. The patient demonstrated no symptoms associated with the bilateral CPA lipomas. Eight cases of bilateral CPA lipomas were identified in the literature review and are summarized. Conservative management is the consensus strategy, given minimum growth of the tumor and the high risk of surgical intervention. This is the first reported case of bilateral CPA lipomas in an infant as well as the first with a coexisting intracranial malformation. Intracranial lipomas share an extremely low growth rate and typically do not cause severe symptoms. The management of asymptomatic or mildly symptomatic bilateral CPA lipomas is usually conservative.

Frailty Assessment Can Enhance Current Risk Prediction Tools in Emergency Laparotomy: A Retrospective Cohort Study.

We set out to assess the performance of the P-POSSUM and NELA risk prediction tool (NELA RPT), and hypothesized that combining them with the Clinical Frailty Scale (CFS) would significantly improve their performance. Emergency laparotomy (EL) is a high-risk surgical intervention, particularly for elderly patients with marked comorbidities and frailty. Accurate risk prediction is crucial for appropriate resource allocation, clinical decision making, and informed consent. Although patient frailty is a significant risk factor, the current risk prediction tools fail to take frailty into account. In this retrospective single-center cohort study, we analyzed all cases entered into the NELA database from the Oxford University Hospitals between 01.01.2018 and 15.06.2021. We analyzed the performance of the P-POSSUM and NELA RPT. Both tools were modified by adding the CFS to the model. The discrimination of both the P-POSSUM and NELA RPT was good, with a slightly worse performance in the elderly. Adding CFS into the P-POSSUM and NELA RPT models improved both tools in the elderly [AUC from 0.775 to 0.846 (p < 0.05) from 0.814 to 0.864 (p < 0.05), respectively]. The improvement of the NELA RPT across all age groups did not reach statistical significance. The CFS grade was associated with 30-day mortality in patients aged > 65years. However, in younger patients, this effect was less marked than in the elderly. Our analysis demonstrated a significant improvement in the P-POSSUM and NELA risk models when combined with the CFS. Frailty also increases the 30-day mortality after EL in younger individuals.

ORAL ANTİKOAGÜLASYON İLE TEDAVİ EDİLEN SERBEST YÜZEN SOL ATRİYAL TOP TROMBÜSÜ

Transesophageal echocardiography (TEE) revealed a free-floating left atrial ball thrombus in a 56-year-old male patient who was taking warfarin for mechanical prosthetic mitral valve and had recently short-term warfarin interruption for noncardiac surgery and bridging with enoxaparin was admitted to an external center for left abdominal pain and after the detection of spleen and renal infarct, the patient was referred to us for further examination. The patient, who was considered to be at high risk for surgical intervention by the cardiac surgeons, was treated with a warfarin regimen and on the 14th day of the treatment, computed tomography (CT) scan showed that the thrombus disappeared. According to this case report, if patients who have a free-floating left atrial ball thrombus are at high risk for surgical intervention, warfarin therapy can be considered as an alternative to surgery.

Identifying Patterns in Preoperative Communication about High-Risk Surgical Intervention: A Secondary Analysis of a Randomized Clinical Trial.

Surgeons are entrusted with providing patients with information necessary for deliberation about surgical intervention. Ideally, surgical consultations generate a shared understanding of the treatment experience and determine whether surgery aligns with a patient's overall health goals. In-depth assessment of communication patterns might reveal opportunities to better achieve these objectives. We performed a secondary analysis of audio-recorded consultations between surgeons and patients considering high-risk surgery. For 43 surgeons, we randomly selected 4 transcripts each of consultations with patients aged ≥60 y with at least 1 comorbidity. We developed a coding taxonomy, based on principles of informed consent and shared decision making, to categorize surgeon speech. We grouped transcripts by treatment plan and recorded the treatment goal. We used box plots, Sankey diagrams, and flow diagrams to characterize communication patterns. We included 169 transcripts, of which 136 discussed an oncologic problem and 33 considered a vascular (including cardiac and neurovascular) problem. At the median, surgeons devoted an estimated 8 min (interquartile range 5-13 min) to content specifically about intervention including surgery. In 85.5% of conversations, more than 40% of surgeon speech was consumed by technical descriptions of the disease or treatment. "Fix-it" language was used in 91.7% of conversations. In 79.9% of conversations, no overall goal of treatment was established or only a desire to cure or control cancer was expressed. Most conversations (68.6%) began with an explanation of the disease, followed by explanation of the treatment in 53.3%, and then options in 16.6%. Explanation of disease and treatment dominate surgical consultations, with limited time spent on patient goals. Changing the focus of these conversations may better support patients' deliberation about the value of surgery.Trial registration: ClinicalTrials.gov Identifier: NCT02623335. In decision-making conversations about high-risk surgical intervention, surgeons emphasize description of the patient's disease and potential treatment, and the use of "fix-it" language is common.Surgeons dedicated limited time to eliciting patient preferences and goals, and 79.9% of conversations resulted in no explicit goal of treatment.Current communication practices may be inadequate to support deliberation about the value of surgery for individual patients and their families.

Nonsize Criteria for Surgical Intervention on the Ascending Thoracic Aorta.

For decades, aortic surgery has relied on size criteria for intervention on the ascending aorta. While diameter has served well, diameter alone falls short of an ideal criterion. Herein, we examine the potential application of other, nondiameter criteria in aortic decision-making. These findings are summarized in this review. We have conducted multiple investigations of specific alternate nonsize criteria by leveraging our extensive database, which includes complete, verified anatomic, clinical, and mortality data on 2,501 patients with thoracic aortic aneurysm (TAA) and dissections (198 Type A, 201 Type B, and 2102 TAAs). We examined 14 potential intervention criteria. Each substudy had its own specific methodology, reported individually in the literature. The overall findings of these studies are presented here, with a special emphasis on how the findings can be incorporated into enhanced aortic decision-making-above and beyond sheer diameter. The following nondiameter criteria have been found useful in decision-making regarding surgical intervention. (1) Pain: In the absence of other specific cause, substernal chest pain mandates surgery. Well-developed afferent neural pathways carry warning signals to the brain. (2) Aortic length/tortuosity: Length is emerging as a mildly better predictor of impending events than diameter. (3) Genes: Specific genetic aberrations provide a powerful predictor of aortic behavior; malignant genetic variants obligate earlier surgery. (4) Family history: Aortic events closely follow those in relatives with a threefold increase in likelihood of aortic dissection for other family members once an index family dissection has occurred. (5) Bicuspid aortic valve: Previously thought to increase aortic risk (as a "Marfan light" situation), current data show that bicuspid valve is not a predictor of higher risk. (6) Diabetes actually protects against aortic events, via mural thickening and fibrosis. (7) Biomarkers: A specialized "RNA signature test" identifies aneurysm-bearing patients in the general population and promises to predict impending dissection. (8) Aortic stress: Blood pressure (BP) elevation from anxiety/exertion precipitates dissection, especially with high-intensity weightlifting. (9) Root dilatation imposes higher dissection risk than supracoronary ascending aneurysm. (10) Inflammation on positron emission tomography (PET) imaging implies high rupture risk and merits surgical intervention. (11) A KIF6 p.Trp719Arg variant elevates aortic dissection risk nearly two-fold. (12) Female sex confers some increased risk, which can be largely accommodated by using body-size-based nomograms (especially height nomograms). (13) Fluoroquinolones predispose to catastrophic dissection events and should be avoided rigorously in aneurysm patients. (14) Advancing age makes the aorta more vulnerable, increasing likelihood of dissection. In conclusion, nondiameter criteria can beneficially be brought to bear on the decision to observe or operate on specific TAA.

Preoperative Stress Testing before Non-Cardiac Surgery.

The current guidelines from various medical societies provide a good summary of data regarding various preoperative exercise tests in patients prior to non-cardiac surgical interventions. However, there is no consensus among experts on the appropriateness of these methods for identifying risk groups for potential perioperative complications. A large volume of published studies describes the role of preoperative exercise stress testing impact in improving the prediction of potential cardiovascular (CV) risk in patients after non-cardiac surgery. Numerous stress tests are available in clinical practice, and the methods used and the best choice depends on the purpose of the study and the availability of equipment in the hospital. Traditionally, the value of exercise electrocardiography (ECG), or ECG stress test, has been based on the belief that it is beneficial for perioperative cardiac risk prediction. However, in the past two decades, the key role of this method has lost its importance due to the growing trend toward the use of imaging techniques. Moreover, in light of current trends, the six-minute walk test (6MWT) is a helpful tool in preoperative assessment and plays an important role in postoperative rehabilitation. Interestingly, the recent finding showed how 6MWT affects the risk of postoperative complications. Cardiopulmonary testing, as a dynamic clinical tool, determines the cardiorespiratory status of a patient. Various clinical indications for cardiopulmonary exercise testing include evaluation of therapy, stratification of risk factors, diagnosis of disease, and control of physical activity. Stress testing is one of the most practical ways of predicting perioperative risk and managing patients. This test is based on ischemia provoked by pharmacological agents or exercise. There is no established evidence of a significant advantage of pharmacological stress over exercise stress imaging in subjects who are capable enough to be physically active. All of these studies examined a stress test for induced myocardial ischemia. Currently, there are no data on the use of ischaemic stress tests, especially diastolic stress tests, in the assessment of perioperative risk before non-cardiac surgical interventions. We consider it promising and essential to continue research in this direction in patients with coronary heart disease and other categories of cardiac patients, in particular, comorbid and low-symptomatic individuals, before elective high-risk surgical interventions.

A novel mini-invasive step-up approach for the treatment of severe acute pancreatitis with extensive infected necrosis: A single center case series study.

Complete removal of necrosis is critical for treating patients with severe acute pancreatitis (SAP) presenting infection of pancreatic necrosis (IPN). Frequently used mini-invasive methods include the surgical step-up approach suitable for necrosis extending laterally, whereas the endoscopic step-up approach is suitable for medial necrosis. However, in patients with extensive IPN, either approach alone usually has limited treatment effects. We describe a case series of combined mini-invasive step-up approach for treating extensive IPN. Patients were diagnosed with SAP and had extensive IPN. Seven patients with SAP and extensive IPN were enrolled. All patients underwent a combined step-up approach comprising 4 steps: percutaneous catheter drainage, continuous negative pressure irrigation (CNPI), percutaneous endoscopic necrosectomy (PEN), and transgastric necrosectomy (TN). The median interval from symptom onset to percutaneous catheter drainage and CNPI was 11 days (range, 6-14) and 18 days (range, 14-26), and the median CNPI duration was 84 days (range, 54-116). The median interval from the onset of symptoms to PEN and TN was 36 days (range, 23-42) and 41 days (range, 34-48), respectively, and the median number of procedures was 2 (range, 1-2) for PEN and 3 (range, 2-4) for TN. Only a minor case of abdominal bleeding and a pancreatic-cutaneous fistula were reported, both resolved after conservative treatment. The median length of stay in the intensive care unit was 111 days (range, 73-133); all patients survived. This mini-invasive step-up approach shows promising clinical effects and is relatively safe in critically ill patients with extensive IPN and high-risk surgical intervention.

Smoking Is Associated With a Higher Risk of Surgical Intervention for Thyroid Eye Disease in the IRIS Registry

To describe the association of smoking status with surgical intervention for thyroid eye disease (TED) at the population-level. Retrospective cohort study. This study included all adults (aged ≥18 years) with Graves disease in the Intelligent Research in Sight (IRIS) Registry (January 1, 2013, to December 31, 2020). The primary outcome was surgical intervention for TED, stratified into orbital decompression, strabismus surgery, and eyelid recession surgery. The Kaplan-Meier estimated 5-year cumulative probability for each surgical intervention was calculated. Multivariable Cox regression was used to evaluate the association between smoking status and each surgical intervention, adjusting for age, sex, race, ethnicity, and geographic region. This study included 87,774 patients. Median age was 59 years (IQR, 48-68 years); 81% were female patients. Current smokers had a greater 5-year cumulative probability of orbital decompression (3.7% vs 1.9%; P < .001), strabismus surgery (4.6% vs 2.2%; P < .001), and eyelid recession (4.1% vs 2.6%; P < .001) compared to never smokers. After adjusting for demographic factors, current smokers were at greater risk for orbital decompression (hazard ratio [HR], 2.1; 95% CI, 1.8-2.4; P < .001), strabismus surgery (HR, 2.0; 95% CI, 1.8-2.3; P < .001), and eyelid recession (HR, 1.7; 95% CI, 1.5-1.9; P < .001) than never smokers. Former smokers were at higher risk for each type of surgery for TED, albeit at lower levels than current smokers. Smoking was associated with increased risk of surgical intervention for TED in the IRIS Registry. Former smokers were at a lower risk than current smokers, supporting the role of smoking cessation on lowering the burden of surgical disease at the population-level.

Risk factors associated to argon plasma coagulation treatment failure in patients with chronic radiation proctopathy.

argon plasma coagulation (APC) is the current endoscopic treatment of choice for patients who develop chronic radiation proctopathy. The aim of this study was to identify risk factors associated with treatment failure. one hundred and ninety-nine patients treated with argon plasma coagulation in a single center were retrospectively analyzed. twenty-four (12.06 %) patients were classified as APC treatment failures. Requirement of red blood cells transfusion and/or hemoglobin < 7 g/dl (OR 12.19, 95 % CI: 2.78-53.45, p < 0.001) and severe bleeding frequency (OR 2.76, 95 % CI: 1.13-6.72, p = 0.03) at diagnosis and prior to endoscopic therapy were associated with argon plasma coagulation treatment failure. Nineteen patients of the successful therapy group developed bleeding recurrence; no risk factors were associated with a shorter recurrence-free time. More than four APC sessions were associated to a higher risk of surgical intervention for bleeding control (OR 87.00, 95 % CI: 10.23-740.18, p < 0.001). requirement of red blood cells transfusion and/or hemoglobin < 7 g/dl and a severe bleeding frequency (more than five days per week) were identified as the most important risk factors for treatment failure in patients with chronic radiation proctopathy.

Identifying Patterns in Preoperative Communication About High-Risk Surgical Intervention

Identifying Patterns in Preoperative Communication About High-Risk Surgical Intervention

S187 Percutaneous Endoscopic Colostomy: A Systematic Review of More Than Two Decades Experience

Introduction: Percutaneous endoscopic colostomy (PEC) is a minimally invasive procedure used to treat recurrent colonic pseudo-obstruction, sigmoid volvulus, chronic intracTable constipation, and neurogenic bowel. Traditional management of these conditions involving surgical colostomy or bowel resection in many cases has been replaced by percutaneous approaches under imaging or endoscopic guidance due to high rates of technical success and low morbidity rates. We conducted a systematic literature review to summarize the use, indications, and complications of PEC in adult patients. Methods: A systematic literature review was conducted using PubMed, Medline, Google Scholar, and Embase to identify patients who had undergone PEC for any indication. The search terms used were “percutaneous endoscopic colostomy”, “percutaneous endoscopic cecostomy”, “percutaneous cecostomy”, and “percutaneous colostomy”. Exclusion criteria were colostomy tubes that were not placed endoscopically. Results: A total of 11 observational studies (3 prospective, 8 retrospective), 18 case reports, and 7 case series between 1998 and 2022 were identified. A total of 318 patients who underwent PEC were identified. The mean age was 66.4 ± 23.5 and 64% were male. The most common indication was sigmoid volvulus (n= 131) followed by pseudo-obstruction (n=43), chronic intrac table constipation (n=83), neurogenic bowel (n=45), and others (n=9). The procedure was technically successful in 311 patients (97.7%). The total complication rate was 37.6%, 83.5% (n=66) of which were minor complications such as pain, bleeding, infection, leakage, and 16.4% (n=13) of which were major complications such as peritonitis, pneumoperitoneum, and sepsis. PEC-related mortality was 1.3% (n=4). The most common locations for tube placement were the left colon (59%) followed by right colon (13%), the rest of the cases the location was not reported. The number of tubes removed was 57, 8 due to symptom resolution, 3 for planned colostomy, and 1 for pain. (Figure) Conclusion: PEC is an underutilized procedure that offers a viable treatment alternative for select patients who are deemed high risk for surgical intervention and in whom conservative therapy is unsuccessful. It can lead to durable relief of symptoms with good technical success and low risk of major complications. Further prospective studies are needed to establish the optimal placement technique, long-term efficacy, and safety.Figure 1.: Percutaneous Endoscopic Colostomy tube indications

Surgical Management of IE Patients Within the Tasmanian Population

Infective endocarditis (IE) is a high morbidity and mortality condition, often requiring high-risk surgical intervention. Our aim was to identify the demographics of IE patients requiring this procedure, and overall intervention rate.

Abstract 10206: First in-vivo Evidence of Aureolysin ( aur ) Up-Regulation by Staphylococcus Aureus Causing Invasive Prosthetic Valve Endocarditis

Background: Staphylococcus aureus prosthetic valve endocarditis (PVE) is resistant to antimicrobial therapy and commonly associated with tissue invasion, which necessitates complex high risk surgical intervention for cure. Hypothesis: S. aureus virulence in infective endocarditis (IE) is dynamic and changes upon colonizing cardiac valves from blood stream. Methods: Six patients undergoing cardiac surgery for left-sided S. aureus IE, 3 native (NVE) and 3 PVE, were included in this study. Vegetation samples were collected during surgery as well as corresponding blood culture isolates during S. aureus bacteremia. Total RNA was extracted from all samples and underwent mRNA sequencing for transcriptomic analysis of S. aureus . Data was pooled into STAR aligner and gene expression related to virulence factors was compared between different groups (Deseq2; p-value &lt; 0.05 for statistical significance). Results: In NVE vegetations, S. aureus showed an increased expression of genes associated with biofilm formation, cell division, and metabolic activity, when compared to blood culture isolates (e.g. rsmA , agrB , dnaK , clpB , ezrA , fusA , ftsZ , adh , pstS , qoxA ). S. aureus isolated from blood cultures had significantly higher expression of clfA (encoding for clumping factor A) compared to cardiac vegetations. Interestingly, in PVE vegetations, S. aureus had a significant higher expression of aur (encoding for metalloprotease aureolysin) compared to corresponding blood culture isolates or NVE vegetations. Aureolysin is an important virulence factor responsible for immune evasion and toxin production. Conclusions: In clinical IE, S. aureus up-regulates genes responsible for biofilm formation when attached to cardiac valves. Planktonic S. aureus cells in the blood stream express clfA , which could bind to fibrinogen to clump within platelet network to form vegetations. On prosthetic valves, S. aureus expresses aureolysin, which could function to evade the host immune response and promote destruction of cardiac tissues. These novel in-vivo findings provide explanations for S. aureus IE pathophysiology that warrant further investigation.

Outcomes of Pediatric Patients with Intracranial Arteriovenous Malformation Treated With Proton Beam Stereotactic Radiosurgery

Intracranial arteriovenous malformations (AVMs) pose a significant concern within the pediatric population given the projected life span of patients and the high cumulative risk of hemorrhage per year. The use of proton radiation allows for a conformal delivery of radiation dose that potentially minimizes the exposure of surrounding normal brain tissue to harmful treatment effects. The purpose of this study is to evaluate the response and toxicity rates of pediatric patients with intracranial AVMs treated at this institution with proton-based stereotactic radiosurgery (SRS).This IRB-approved single-institution study examines a cohort of 24 pediatric patients (≤ 18 years old) with 25 brain AVM lesions treated with proton radiosurgery between 2006 and 2018. Median age of patients was 14 years old, and median target volume was 8.14 cc. Lesions were treated to 20-25 Gy in 1 or 2 fractions, with 18 (72%) lesions receiving 25 Gy in 2 fractions. Per institutional guidelines, new lesions ≥5cc and lesions ≤15cc undergoing re-treatment received treatment in 2 fractions. Those in high-risk locations were also considered for 2-fraction treatment per physician discretion. Lesions were classified by Spetzler-Martin grading scale, ranging from grade 2 (24%), grade 3 (52%), and grade 4 (24%). There were no grade 1 or 5 lesions. 12 patients (48%) underwent prior surgery or embolization.Median follow-up time was 54 months. Of 25 treated lesions, 12 (48%) were found to have complete obliteration of nidus confirmed on angiogram, with first imaging showing obliteration at a median time of 38 months. Another 12 (48%) patients exhibited residual nidus on imaging with noticeable decrease in size. Of these patients, one was treated with a second course of proton-based SRS as an adult due to symptoms from the residual nidus. One (4%) patient had minimal decrease in lesion size on 3-year follow-up imaging with subsequent intracranial hemorrhage shortly afterwards, requiring resection and second course of radiosurgery at their local institution. All patients tolerated proton radiation treatment well without any toxicity noted, with the exception of one who experienced nonspecific intracranial edema requiring temporary steroid treatment. No patient deaths were observed at last follow-up.Stereotactic irradiation is often offered as a treatment option for intracranial AVMs given their high propensity to bleed, especially for those considered high risk for surgical intervention. While dose prescriptions do vary among published proton treatment experiences, this study shows the use of 20-25 Gy in one- to two-fractions to safely treat intracranial AVMs in pediatric patients while maintaining comparable efficacy rates.B.K. Lee: Employee; Amgen. L.N. Loredo: None. J.D. Slater: None.

Comparison of external dacryocystorhinostomy versus injection botulinum toxin in the management of functional epiphora

To compare the efficacy of external dacryocystorhinostomy (DCR) and botulinum toxin-A in the management of functional epiphora.A prospective, comparative, interventional study included 45 patients with functional epiphora out of which 20 patients had undergone external dacryocystorhinostomy and 25 patients received 5 units of injection botulinum toxin in the palpebral lobe of lacrimal gland as per the patient’s preference. All patients underwent syringing and fluorescein dye disappearance testing before the procedure. Epiphora was graded subjectively with Munk scores obtained before and after intervention. Duration of side effects and severity were also noted.This study showed functional epiphora common in elderly age group. Female constitued of 71.11% and male 28.89 % with female: male ratio of 2.4:1. Left eye (42.22%) predominantly involved. The overall success rate at 6 months after surgery for external DCR was 95% and that of injection botulinum was 91.17%. The overall success rate in both the group was not statistically significant(p&amp;#62;0.05%). Improvement in epiphora graded by Munk score was statistically significant after intervention in both the groups(p&amp;#60;0.05%). This study showed injection Botulinum toxin can be considered as an alternative management in case of functional epiphora for patient who do not want to undergo surgical intervention and for those with co-morbid conditions with high risk for surgical intervention like DCR.