non-HP Group Research Articles

Hepatopulmonary Syndrome and Liver Transplantation: Impact on Survival and Postoperative Complications.

BACKGROUND Liver transplantation (LT) is the preferred treatment for patients with cirrhosis who have hepatopulmonary syndrome (HPS). However, the effect of HPS on LT remains controversial. We assessed the correlation between HPS severity and LT survival and compared the incidence of postoperative complications between patients with and without HPS undergoing LT. MATERIAL AND METHODS We retrospectively reviewed the recipients who received living-donor LT in our institute between January 2016 and July 2019. Patients with HPS (HPS group) and patients without HPS (non-HPS group) were included in our study. HPS is defined as a defect in arterial oxygenation caused by the presence of intrapulmonary vascular dilatations, which is found by transthoracic echocardiography with pre-existing liver cirrhosis. HPS severity was graded according to the value of partial pressure of arterial oxygen. The demographic characteristics and clinical outcomes between the HPS and non-HPS groups were compared. RESULTS A total of 181 patients were enrolled. Among them, 104 patients (57.5%) had HPS. The mean overall survival of HPS and non-HPS groups was 69.82±3.1 vs 63.36±3.8 months, with no significant difference (P=0.332). The overall survival between different degrees of HPS was also compared, and showed no significant difference (P=0.466). The HPS group had a higher incidence of delayed extubation (22.1% vs 10.4%, P=0.028) and chest pigtail catheter insertion (16.3% vs 10.4%, P=0.012). Nevertheless, it did not lead to a longer Intensive Care Unit/hospital stay or higher risk of short-term mortality. CONCLUSIONS Patients with HPS tend to have more post-LT pulmonary complications, but the overall survival is not adversely influenced, regardless of the severity of HPS.

Helicobacter pylori and Its Treatment Impact on Immune-Mediated Ocular Diseases

ABSTRACT Purpose Helicobacter pylori (HP), which colonizes exclusively in the gastrointestinal tract, has been reported to dysregulate the immune response and gives rise to several extra-gastrointestinal autoimmune disorders. However, the relationship between HP and immune-mediated ocular diseases remains ambiguous. This study aims to clarify the association between immune-mediated ocular diseases and HP infection, as well as the impact of HP treatment on the incidence of immune-mediated ocular diseases. Methods This is a retrospective population-based study using National Health Insurance Research Database in Taiwan. Patients with newly diagnosed peptic ulcer disease or HP infection between 2009 and 2015 were identified as HP group and compared to the non-HP group with one-to-one exact matching. Moreover, the incident risk of immune-mediated ocular diseases and its two subgroups (ocular surface and orbital inflammation group, intraocular inflammation group) were compared in HP patients with or without treatment. Results A total of 1,030,119 subjects in the non-HP group and 1,030,119 patients in the HP group were enrolled. The incidence rate of immune-mediated ocular diseases was significantly higher in the HP group (95% confidence interval (CI): 2.534–2.547). The incident rate ratio was significantly higher in HP with treatment than without treatment (HR: 1.654, 95% CI: 1.641–1.668). The Cox proportional hazards regression model demonstrated a significantly increased HR of immune-mediated ocular diseases in HP treated group (HR: 2.265, 95% CI: 2.024–2.534) and less increased HR in HP non-treated group (HR: 1.427, 95% CI: 1.273–1.598) when comparing to non-HP group. Subgroup analysis demonstrated a significantly higher incidence rate of ocular surface and orbital inflammation as well as intraocular inflammation in the HP group. Conclusion This study illustrated a higher incidence of immune-mediated ocular diseases in HP infection, and a heightened risk following HP eradication.

Clinical Features and Prognostic Analysis of Newly Diagnosed Diffuse Large B-cell Lymphoma Combined with Hemophagocytic Syndrome

To compare the clinical features and prognosis between newly diagnosed diffuse large B-cell lymphoma (DLBCL) patients with and without hemophagocytic syndrome (HPS). The clinical data of 45 DLBCL patients in Gansu Provincial Hospital from January 2012 to December 2021 were retrospectively analyzed. The patients were divided into HPS group (15 cases) and non-HPS group (30 cases). The clinical features and prognosis of the two groups were compared, and survival analysis was performed using Kaplan-Meier method. Patients with HSP were mostly characterized by fever, cytopenia and splenomegaly. The levels of ferritin and soluble CD25 increased in all patients. The level of fibrinogen decreased in 66.67% patients, while triglyceride increased in 53.33% patients, and bone marrow hemophagocytosis occurred in 80.00% patients. Compared with non-HSP group, the proportions of patients with advanced stage (Ann Arbor stage III/IV) and lactate dehydrogenase (LDH) ≥240 U/L were higher in HSP group (both P < 0.05). The median survival time of HSP group was 8.0 months, which was significantly shorter than 45.5 months of non-HSP group (P < 0.001). The DLBCL patients with HPS have later Ann Arbor stage, higher LDH and shorter overall survival time compared with patients without HPS.

Combination of intraoperative indocyanine green video-angiography FLOW 800 and computed tomography perfusion to assess the risk of cerebral hyperperfusion syndrome in chronic internal carotid artery occlusion patients after revascularization surgery.

To study the changes of corticocerebral hemodynamics in surgical area and postoperative hyperperfusion syndrome in patients with chronic internal carotid artery occlusion (CICAO) by intraoperative indocyanine green videoangiography (ICGA)-FLOW 800 and CT perfusion after superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery. From October 2019 to January 2021, 77 patients diagnosed with CICAO underwent direct bypass surgery at Huadong hospital (affiliated with Fudan University) were enrolled. Regions of interest (ROIs) at STA, proximal MCA (PMCA), distal MCA (DMCA), cortical blood capillary (CBC), and cortical vein (CV) were identified after anastomosis by ICGV-FLOW 800 including peak fluorescence intensity (PFI), time to peak (TTP), and area under the time curve (AUC) of fluorescence intensity. All patients underwent perfusion-weighted CT before bypass surgery and those patients with HPS were verified by CTP after bypass. 14 patients with HPS were verified by perfusion-weighted CT after bypass. In HPS group, the AUCTTP of DMCA was significantly larger (T = -3.301, p = 0.004) and TTP of CBC was shorter (T = -2.929, p = 0.005) than patients in non-HPS group. The larger AUCTTP of DMCA (OR = 3.024, 95%CI 1.390-6.578, p = 0.0050) was an independent risk factor by further multivariate logistic regression analysis. The hemodynamic changes of cortical vessels during STA-MCA bypass surgery could be recorded accurately by ICGV-FLOW 800. Furthermore, the increased AUCTTP of DMCA and shorter TTP of CBC may be potential risk factors of HPS.

The Characteristic of Transbronchial Lung Cryobiopsy in the Pathological Diagnosis of Hypersensitivity Pneumonitis.

Transbronchial lung cryobiopsy (TBLC) has widely used for the diagnosis of diffuse lung disease. However, it remains unclear whether TBLC is useful for the diagnosis in hypersensitivity pneumonitis (HP). We investigated 18 patients who underwent TBLC and were diagnosed with HP based on pathology or multidisciplinary discussion (MDD). Of the 18 patients, 12 had fibrotic HP (fHP), 2 had non-fibrotic HP (non-fHP) diagnosed with MDD. The remaining 4 patients were diagnosed with fHP by pathology but not by MDD because of clinical features. The radiology and pathology of these cases were compared. All patients with fHP showed radiological findings of inflammation, fibrosis, and airway disease. Conversely, pathology showed fibrosis and inflammation in 11 of 12 cases (92%), but airway disease was significantly less common with 5 cases (42%) (p = 0.014). Non-fHP showed inflammatory cell infiltration mainly in the centrilobule on pathology, which was consistent with radiology. Granulomas were found in 5 patients with HP (36%). In the non-HP group, airway-centered interstitial fibrosis was observed in 3 patients (75%) with pathology. The pathology with TBLC is difficult to evaluate airway disease of HP. We need to understand this characteristic of TBLC to make a MDD diagnosis of HP.

The relationship between Thiol/disulfide homeostasis and endometrial hyperplasia in patients with abnormal uterine bleeding/

Introduction: The role of oxidative stress and antioxidant capacity in the development of endometrial hyperplasia (EH) is controversial. Aim: The study aimed to evaluate Thiol/disulfide Homeostasis and ischemia modified albumin (IMA) levels in patients with EH without atypia. Materials and Methods: In this prospective case-control study, patients with EH without atypia (HP group) (n=28), patients with nonhyperplasia (proliferative/secretory/irregular proliferative/irregular secretory endometrium) (non-HP group) (n=28), and 28 healthy women (control group) were included. The patient's clinical characteristics, serum Thiol/disulfide parameters, and IMA levels were compared between groups. Results: A total of 84 patients were included in the study. Patients’ mean age, BMI, and mean native thiol (-SH-), total thiol (-SH-+-SS-), disulfide (-SS-), and IMA levels were similar among the three groups. The -SS- /-SH- ratio was higher in the HP group than the non-HP group. -SS- /-SH-+-SS- ratio was higher in the HP group vs. the other two groups. The -SS- /-SH-+-SS ratio was higher in the HP group vs. the non-HP group. -SH-/ -SH-+-SS- ratio was lower in the HP group than in the non-HP group. ET was greater in the HP group than in the non-HP and control groups. ET was also significantly greater in the non-HP group vs. in the control group. -SS-/-SH- ratio was found to be predictive with 64% sensitivity and 68% specificity for EH (area under curve = 0.672, p = 0.01). Conclusion and Suggestions: The dynamic thiol/disulfide balance shifted to the disulfide side in women with endometrial hyperplasia.

The effect of the hypertensive phase on the long-term outcomes of Ahmed glaucoma valve (AGV) implantation.

To investigate the long-term effect of hypertensive phase (HP) on the clinical outcomes of Ahmed glaucoma valve (AGV) implantation. The records of patients with different etiologies of glaucoma who underwent AGV implantation with at least 3years of follow-up were retrospectively reviewed. HP was defined as the IOP > 21mm Hg during the first three months after surgery. The main outcome measure was cumulative success defined as 5 < IOP ≤ 21mmHg and 20% reduction from the baseline with or without IOP lowering medications. Results that do not achieve cumulative success or undergo glaucoma reoperation during the follow-up period are considered failures. The secondary outcome measures were intraocular pressure (IOP) and the number of glaucoma medications. A total of 120 patients (28 patients of HP, 92 patients without HP) with an average age (± SD) of 48.9 ± 19.6years and a mean follow-up of 4.5 ± 1.4years were enrolled. The mean duration of survival was 5.3 ± 0.5years in HP which was significantly shorter than 6.4 ± 0.2years in non-HP (log rank = 4.2, P = 0.04). Mean IOP and number of IOP lowering agents were higher in postoperative visits at 1,2, 3, and 4years in HP patients compared with non-HP (all Ps < 0.01). Higher baseline IOP was significantly associated with higher rates of surgical failure. In the long-term follow-up, the duration of survival was significantly longer in the non-HP group. In the non-HP group, the failure rate was significantly lower than the HP group.

Hepatopulmonary syndrome is related to the development of acute-on-chronic liver failure and poor prognosis in cirrhotic patients

Long-term prospective data on hepatopulmonary syndrome (HPS) from a large number of patients, especially in Asian patients, are lacking. We evaluated the long-term prognosis of HPS and the development of acute-on-chronic liver failure (ACLF), and related factors. A total of 142 patients with cirrhosis who underwent saline-agitated contrast echocardiography for the diagnosis of HPS were enrolled and observed prospectively from 2014 to 2019. A total of 59 patients (41%) were diagnosed with HPS (24 grade 1, 23 grade 2, 12 grade 3). Thirty-eight and 37 patients died in the HPS and non-HPS groups, respectively (p < 0.01). The 5-year survival rate was 47% in the HPS group and 62% in the non-HPS group. In the Cox proportional hazards model, HPS and Model for End-stage Liver Disease (MELD) score ≥ 18, and Child-Turcotte-Pugh (CTP) class B/C were significant risk factors for mortality after adjusting for other risk factors (HPS hazard ratio [HR] = 1.9, p = 0.01; MELD score ≥ 18 HR = 2.3, p < 0.01; CTP class B/C HR = 2.9, p < 0.01). Compared to that in non-HPS group, the HPS group had a significantly higher incidence of ACLF during follow-up (p < 0.01) and more frequently presented with lung involvement of ACLF (p = 0.03). In the long-term follow-up cohort, patients with HPS showed poorer prognosis than that of patients without HPS. HPS was a risk factor for ACLF development independent of hepatic dysfunction, and lung involvement was significantly common than without ACLF.

Quality of end-of-life care of home-based care with or without palliative services for patients with advanced illnesses.

Palliative care has improved quality of end-of-life (EOL) care for patients with cancer, and these benefits may be extended to patients with other serious illnesses. EOL care quality for patients with home-based care is a critical problem for health care providers. We compare EOL quality care between patients with advanced illnesses receiving home-based care with and without palliative services.The medical records of deceased patients who received home-based care at a community teaching hospital in south Taiwan from January to December 2019 were collected retrospectively. We analyzed EOL care quality indicators during the last month of life.A total of 164 patients were included for analysis. Fifty-two (31.7%) received palliative services (HP group), and 112 (68.3%) did not receive palliative services (non-HP group). Regarding the quality indicators of EOL care, we discovered that a lower percentage of the HP group died in a hospital than did that of the non-HP group (34.6% vs 62.5%, P = .001) through univariate analysis. We found that the HP group had lower scores on the aggressiveness of EOL care than did the non-HP group (0.5 ± 0.9 vs 1.0 ± 1.0, P<.001). Furthermore, palliative services were a significant and negative factor of dying in a hospital after adjustment (OR = 0.13, 95%CI = 0.05–0.36, P < .001).For patients with advanced illnesses receiving home-based care, palliative services are associated with lower scores on the aggressiveness of EOL care and a reduced probability of dying in a hospital.

Does a history of periodontal disease affect implant survival?

Data sources Three electronic databases were searched (Medline, EMBASE and Cochrane Central) with date of publication between January 2003 and May 2018. Only articles written in English were included. Following electronic searches, the authors conducted manual searches of oral implant/periodontal journals from January 2012 to May 2018. In the event of disagreement on article selection, a further senior reviewer would make the final decision on its inclusion or exclusion following discussion.Study selection In total, 172 articles from the electronic search and ten from manual search were identified for initial screening. From the title and abstract, 18 articles were identified for full-text screening. Following this, 13 articles were included for quantitative synthesis and meta-analysis. The articles assessed the impact of history of periodontitis (HP) on implant survival, radiographic bone loss, pocket depth and bleeding on probing around the dental implant. All studies were either cohort or controlled studies. Seven of the 13 identified studies were prospective. Included studies fulfilled the following criteria: any human studies with supportive periodontal treatment (SPT) application, details of SPT provided in the studies for implant maintenance, compares the outcomes of implants from both patients with and without a HP and peri-implant conditions recorded.Data extraction and synthesis Data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. The Newcastle-Ottawa Scale was used to carry out quality assessment. Data was extracted to calculate risk ratio (RR) of implant survival, weighted mean difference (WMD) for radiographic bone loss, pocket depth, bleeding on probing and plaque index in patients with and without a HP.Results Implant survival rate was assessed as the primary outcome. Secondary outcomes also assessed were radiographic bone loss, pocket depth, bleeding on probing and plaque indices. In implants with rough surfaces, the HP group showed a reduced implant survival rate (RR: 0.96, 95% CI: 0.94-0.98, P <0.001) even under regular supportive post-implant treatment. They also showed more radiographic marginal bone loss (WMD: 0.34 mm, 95% CI: 0.2-0.48, P <0.001), pocket depth (WMD: 0.47 mm, 95% CI: 0.19-0.74, P <0.001) and bleeding on probing (WMD: 0.08 mm, 95% CI: 0.04-0.11, P <0.001) when compared to the non-HP group. In implants with a machined surface, again the HP group had more radiographic bone loss (WMD: 0.88 mm, 95% CI: 0.65-1.11, P <0.001) than the non-HP group. However, in implants with machined surfaces, there was no statistically significant difference in survival rate between HP and non-HP groups (RR: 0.98, 95% CI: 0.92-1.04, P = 0.895).Conclusion In implants with rough surfaces, a history of periodontal disease has a negative impact on survival rate, even with SPT.

Does Hemoperfusion Increase Survival in Acute Paraquat Poisoning? A Retrospective Multicenter Study.

The efficacy of hemoperfusion (HP) in patients with acute paraquat poisoning (PQ) remains controversial. We conducted a multi-center retrospective study to include acute PQ-poisoned patients admitted to two tertiary medical centers between 2005 and 2015. We used the Severity Index of Paraquat Poisoning (SIPP) to stratify the severity of PQ-poisoned patients. The indication to start HP was a positive result for the semiquantitative urine PQ test and presentation to the hospital was within 24 h. Early HP was defined as the first session of HP performed within five hours of PQ ingestion. A total of 213 patients (100 HP group, 113 non-HP group) were eligible for the study. The overall 60-day mortality of poisoned patients was 75.6% (161/213). Multivariate Cox regression analysis showed no statistically significant difference in 60-day survival between HP and non-HP groups (95% confidence interval (CI): 0.84–1.63, p = 0.363). Further subgroup analysis in the HP group showed early HP (95% CI: 0.54–1.69, p = 0.880), and multiple secessions of HP (95% CI: 0.56–1.07, p = 0.124) were not significantly related to better survival. Among acute PQ-poisoned patients, this study found that HP was not associated with increased 60-day survival. Furthermore, neither early HP nor multiple secessions of HP were associated with survival.

CAPACITY OF EXERCISE AND SURVIVAL IN PATIENTS WITH CIRRHOSIS WITH AND WITHOUT HEPATOPULMONARY SYNDROME AFTER LIVER TRANSPLANTATION.

Hepatopulmonary syndrome (HPS) is a complication associated with cirrhosis that may contribute to worsening exercise capacity and reduced survival after liver transplantation (LT). To evaluate exercise capacity, complications and survival after LT in patients with cirrhosis and HPS and to compare these results with the results of patients with cirrhosis without HPS. A prospective cohort study, consisting initially of 178 patients, of whom 90 underwent LT (42 with HPS and 48 without HPS). A previous evaluation consisted of the six-minute walk test (6MWT), an exercise test and manovacuometry. Those who underwent LT were evaluated for the mechanical ventilation time (MV), noninvasive ventilation (NIV) use, and survival two years after the procedure. In the statistical analysis, we used the Kolmogorov-Smirnov test, Student's t-test, the linear association square test, and the Kaplan-Meier survival curve. The data were analyzed with the SPSS 16.00 program and considered significant at P<0.05. The HPS group demonstrated a lower peak of oxygen consumption (VO2peak) (14.2±2.3 vs 17.6±2.6) P<0.001 and a shorter distance walked on the 6MWT (340.8±50.9 vs 416.5±91.4) P<0.001 before LT compared with the non-HPS group. The transplanted patients with HPS remained longer hours in MV (19.5±4.3 vs 12.5±3.3) P=0.02, required more NIV (12 vs 2) P=0.01, and had lower survival two years after the procedure (P=0.01) compared with the transplanted patients without HPS. Patients with HPS had worse exercise capacity before LT, more complications and shorter survival after this procedure than patients without HPS.

Hartmann's Pouch Stones and Laparoscopic Cholecystectomy: The Challenges and the Solutions.

Background & Objective:Hartmann's pouch stones (HPS) encountered during laparoscopic cholecystectomy (LC) may hinder safe dissection of the cystic pedicle or be complicated by mucocele, empyema, or Mirizzi syndrome; distorting the anatomy and increasing the risk of bile duct injury. We studied the incidence, presentations, operative challenges, and outcomes of HPS.Methods:A cohort study of a prospectively maintained database of LCs and bile duct explorations performed by a single surgeon. Patients were divided into two groups: those with HPS and those without. Patients' demographics, clinical presentation, intra-operative findings, and postoperative outcomes were compared.Results:Of the 5136 patients, 612 (11.9%) had HPS. The HPS group were more likely to present with acute cholecystitis (27.9% vs 5.9%, P = .000) and more patients underwent emergency LC (50.7% vs 41.5%, P = .000). The HPS group had more difficult cholecystectomies, with 46.1% vs 11.8% in the non-HPS group being operative difficulty grade 4 and 5. Mucocele, empyema, and Mirizzi syndrome were more common in the HPS group (24.0% vs 3.7% P = .000, 30.9% vs 3.7% P = .000, 1.8% vs 0.9% P = .000, respectively). There was no significant difference in the open conversion rate or complications.Conclusion:HPS increase the difficulty of LC. Surgeons should be aware of their presence and should employ appropriate dissection strategies. Sharp or diathermy dissection should be avoided. Dislodging the stone into the gall bladder, stone removal, swab dissection, and cholangiography are useful measures to avoid ductal injury and reduce the conversion rate.

Is History of Periodontal Disease Still a Negative Risk Indicator for Peri-implant Health Under Supportive Post-implant Treatment Coverage? A Systematic Review and Meta-analysis.

Among all previous studies, history of periodontitis (HP) has been regarded as a negative indicator for peri-implant health. However, the role of HP under regular supportive post-implant treatment (SPT) has not yet been evaluated. The aim of this review was to evaluate whether HP remains a negative indicator even under regular SPT in terms of clinical outcomes. Two independent reviewers conducted electronic and manual searches of the literature in English from January 2003 to May 2018. Human clinical studies including both patients with and without HP under SPT with more than 1-year follow-up and complete information about peri-implant conditions were included. Risk ratio (RR) for implant survival rate, weighted mean difference (WMD) for radiologic marginal bone loss, pocket depth, bleeding on probing, and Plaque Index were analyzed to compare the outcomes in patients with and without HP. Thirteen human studies fulfilling the inclusion criteria were selected. Based on the results of meta-analyses, in implants with a rough surface, even under the regular SPT, the HP group showed a lower implant survival rate (RR: 0.96, 95% confidence interval [CI]: 0.94 to 0.98, P < .001) and more radiologic marginal bone loss (WMD: 0.34 mm, 95% CI: 0.20 to 0.48, P < .001), pocket depth (WMD: 0.47 mm, 95% CI: 0.19 to 0.74, P < .001), and bleeding on probing (WMD: 0.08 mm, 95% CI: 0.04 to 0.11, P < .001) than the non-HP group. In implants with a machined surface, HP also showed a negative effect on bone loss (WMD: 0.88 mm, 95% CI: 0.65 to 1.11, P < .001). However, in implants with a machined surface, no statistical significance in survival rate was found between HP and non-HP patients (RR: 0.98, 95% CI: 0.92 to 1.04, P = .895). Within the limitations of this review, HP remains a negative indicator for implant survival even under regular supportive post-implant treatment coverage in rough-surfaced implants.

CD177 Expression and Inflammation Grade in Helicobacter pylori-Infected Wild-Type and CD177-/- C57BL/6 Mice.

This study was undertaken to further investigate the CD177 expression in Helicobacter pylori- (Hp-) infected wild-type and CD177−/− C57BL/6 mice, which may be helpful to elucidate the relationship between CD177 and Hp-related gastritis. 20 WT mice were randomly assigned into the Hpss1 WT group (n = 10) and Hp49503 WT group (n = 10); 20 KO mice were randomly assigned into the Hpss1 KO group (n = 10) and Hp49503 KO group (n = 10). The remaining mice served as controls. Mice in the HpSS1 groups and Hp49503 groups were independently infected with corresponding strains. Results showed that the Hp colonization score was related to the grade of mucosal inflammation (P < 0.05). The inflammation grade was comparable between the HpSS1 group and Hp49503 group as well as between the WT group and KO group. In addition, the Hp colonization score was related to the CD177 expression score (P < 0.05). The CD177 expression in the Hp colonization group was higher than that in the non-Hp colonization group (P < 0.05). CD177 expression was positively related to the inflammation grade (P < 0.01). In conclusion, CD177 expression was similar between HP49503- and HPss1-infected WT C57BL/6 mice, and CD177 expression was undetectable in CD177−/− mice. CD177 expression in the gastric mucosa increases with the elevation of inflammation grade. In Hp-infected mice, the inflammation grade had no relationship with the type of Hp strain and the CD177 expression, but the mucosal inflammation score in Hp-infected mice was higher than that in non-Hp infected mice.

11. Spectrum and manifestation of hepato-pulmonary syndrome in 150 consecutive living related pediatric liver transplantation

Background and Aims: Liver transplantation (LT) is challenging in hepatopulmonary syndrome (HPS). Pre-operative pO2 < 50 mmHg and MAAscan showing >20%shunting are believed to predict mortality post-LT. We aim to study profile, impact and outcome of HPS in pediatric-LT and to study use of inhaled nitric oxide (iNO) for refractory hypoxemia post-LT. Methods: Retrospective analysis. Age < 18 years. Study period: 2010-2016. HPS severity graded by 2 methods: pO2 room air (mild: >80 mmHg, moderate: 60–80 mmHg, severe: 50–60 mmHg, very severe <50 mmHg) and CE-ECHO (some shunt:few bubbles, significant shunt:dense opacification). Post- operative course and outcomes-were-studied. iNO used for refractory post-operative hypoxemia (sPO2 < 85% despite FiO2 100%) as per institutionally developed protocol. Results: Out of 150 patients studied, 23 had HPS. Mean age: 6.5 years. Biliary atresia was commonest underlying etiology (52.2%). By oxygenation criteria: Mild HPS:1 2 (52.2%), moderate-HPS:4 (17.3%), severe-HPS:1 (4.7%); very-severe HPS: 6 (26.1%). By CE-ECHO 12 (52.2%) had significant and 11 (47.8%) had some shunt. On MAAscan shunt-fraction ranged from 19.9–73%-it didn’t correlate with severity of pre-operative hypoxemia (p = 0.623), length of ICU stay (LOS) (p = 0.245) or hospital stay (p = 0.479). Patients with very severeHPS (n = 6) had higher LOS (p = 0.031) and duration of oxygen requirement (p = 0.001) compared to rest HPS patients. 4 of these 6 patients had-pO2 < 45 mmHg: this appeared to-be predictor of stormy post-operative course. One-out-of these 4 died-on 7th post-operative-day due-to intracranial-hemorrhage (ICH). Remaining 3 had refractory post-operative hypoxemia, prolonged-LOS and hospital stay. iNO was used in all 3 cases successfully (mean duration of iNO:26.3days). Incidence of hepatic artery thrombosis in HPS-group was 17.3% compared to 3.1% in non-HPS group (3.1%; p = 0.786). PV-thrombosis occurred in 1 (4.3%) in HPS group. ICH occurred in 2, both had pO2 < 45 mmHg. 1 died on POD7 and other recovered with intact neurological outcome. 1-year survival of HPS-group was 86.9% which was similar to nonHPS group (94.4%, p = 0.88). Conclusions: Pediatric LT in HPS, especially if severe is challenging. With good supportive care, outcomes of HPS and non-HPS patients are comparable. pO2 < 45 mm Hg, predicts a difficult post-operative course, rather than mortality. iNO is a successful strategy to overcome refractory postoperative hypoxemia. The authors have none to declare.

Abstract WP355: Evaluation of a Checklist to Identify Early Signs of Hyperperfusion Syndrome After Carotid Endarterectomy

Background and purpose: Hyperperfusion syndrome (HPS) occurs in only 1-3% of patients after carotid endarterectomy (CEA). However, it can cause severe cerebral hemorrhage and may be lethal. Therefore, nurses need to be able to recognize the early signs of HPS and report them to the physician. In this study, we aimed to investigate the applicability of using the Intensive Care Delirium Screening Checklist (ICDSC) to discover early signs of postoperative HPS after CEA, allowing nurses to report the signs and possibly prevent disease progression. Method: The study included 96 Japanese patients average age 71.9 ± 8.3 years old undergoing CEA from May 2008 to May 2017. There were 9 patients in the HPS group and 87 in the non-HPS group. Research design was a methodological study. To analyze differences between normally distributed continuous variables, the average value ± standard deviation was calculated and a t test used to compare between groups. For non-normally distributed continuous variables, the median and the range were calculated, and the Wilcoxon rank sum test was used to compare between groups. Ethical approval was granted by the Ethics Review Committee of the research execution facility. Result: There was no significant difference in the patient characteristics in both groups. There was also no significant difference in the number of patients exhibiting signs of delirium (&gt;4 points in total on the ICDSC) between the HPS group (n=8) and the non-HPS group (n=10). However, patients in the HPS group were unable to engage in conversation, while those in the non-HPS group responded to the nurses’ questions and several patients were able to engage in lucid conversation. The HPS group thus scored significantly higher than the non-HPS group on the "inappropriate speech or mood" ICDSC item (100% in the HPS group vs. 20% in the non-HPS group, P &lt;0.001). In addition, on the "symptom fluctuation" item, the non-HPS group scored significantly higher than the HPS group (0% in the HPS group vs. 100% in the non-HPS group, P &lt;0.001). Conclusion: A total ICDSC score &gt;4 and the presence of "inappropriate speech or mood" or "symptom fluctuation" strongly suggest the presence of HPS. In conclusion suggest that ICDSC is effective in identifying the early clinical signs of HPS after CEA.

Hypoxia preconditioning protects Ca2+-ATPase activation of intestinal mucosal cells against R/I injury in a rat liver transplantation model.

AIMTo investigate the effect of ischaemia and reperfusion (I/R) injury on the Ca2+-ATPase activation in the intestinal tissue of a rat autologous orthotopic liver transplantation model and to determine if hypoxia preconditioning (HP) therapy induces HIF-1α to protect rat intestinal tissue against I/R injury.METHODSRats received non-lethal hypoxic preconditioning therapy to induce HIF-1α expression. We used an autologous orthotopic liver transplantation model to imitate the I/R injury in intestinal tissue. Then, we detected the microstructure changes in small intestinal tissues, Ca2+-ATPase activity, apoptosis, and inflammation within 48 h postoperatively.RESULTSHIF-1α expression was significantly increased in intestinal tissue at 12 h postoperatively in rats that were exposed to a hypoxic environment for 90 min compared with a non-HP group (HP vs AT, P = 0.0177). Pathological analysis was performed on the intestinal mucosa cells, and the cells in the HP group appeared healthier than the cells in the AT group. The Ca2+-ATPase activity in the small intestinal cells in the AT group was significantly lower after the operation, and the Ca2+-ATPase activity in the HP group recovered faster than that in the AT group at 6 h postoperatively (HP vs AT, P = 0.0106). BCL-2 expression in the HP group was significantly higher than that in the AT group at 12 h postoperatively (HP vs AT P = 0.0010). The expression of the inflammatory factors NO, SOD, IL-6, and TNF-α was significantly lower in the HP group than in the AT group.CONCLUSIONHypoxia-induced HIF-1α could protect intestinal mucosal cells against mitochondrial damage after I/R injury. HP could improve hypoxia tolerance in small intestinal mucosal cells and increase Ca2+-ATPase activity to reduce the apoptosis of and pathological damage to intestinal cells. HP could be a useful way to promote the earlier recovery of intestinal function after graft procedure.

Utility of Pulse Oximetry Screening for Hepatopulmonary Syndrome in Low Resource Settings

Introduction: Hepatopulmonary syndrome (HPS) is present in up to 30% of patients with cirrhosis and increases mortality even after liver transplant. HPS and pulse oximetry utility have not been described in Guatemala. Methods: Patients from Hospital Roosevelt in Guatemala City with ultrasound confirmed cirrhosis and no cardiac or lung abnormalities were enrolled from the internal medicine inpatient services and the gastroenterology outpatient clinics. Baseline characteristics for both groups were recorded and all patients underwent proper diagnostic studies. Results: 54 patients were enrolled, of which 17 (32%) were diagnosed with HPS; the most common etiology for liver cirrhosis was chronic alcohol consumption, mean age of diagnosis was 50.4 ±11.8 years. Both groups were similar, differing only in that 6 patients (35%) in the HPS group presented with orthodeoxia compared to 1 patient (2%) in the Non-HPS group (p < 0.001). It was found that with a threshold value of standing SpO2 of ≤96% pulse oximetry had a sensitivity of 100% and specificity of 93% for detecting patients with a PaO2 of ≤60mmHg. Interestingly, in patients with arterial blood gas PaO2 values of ≤60mmHg a diagnosis of HPS could be made with a sensitivity of 94% and specificity of 94%. Conclusion: Pulse oximetry is a useful tool for screening patients with cirrhosis for HPS due to its wide availability and low cost. It has a high sensitivity and specificity for detecting hypoxemia, this is important in low resource settings as in primary care clinics in Guatemala, where access to specialized healthcare workers and technology is not readily available. As our study results show, a standing SpO2 value of ≤96% and arterial blood gas PaO2 value of < 60mmHg can be good indicators of presence of HPS when saline contrast echocardiogram is unavailable. This is the first study to report specificity and sensitivity estimates in a resource-limited practice for non-Caucasian patients at 1500m above sea level. This confirms once again the utility of oximetry as a vital sign, not widely applied in primary care settings. This study should raise awareness to primary health care providers in Guatemala of the relevance of HPS and the importance of early screening and prompt referral of these patients to specialized centers in or outside of the country. Early diagnosis is critical in regions where liver transplant programs are still not available, for appropriate symptomatic management of these patients.Table: Baseline characteristics.Table: Sensitivity and specificity values of standing pulse oximetry with a threshold value of SpO2 96% for detecting patients with a PaO2 of 60mmHg.Table: Sensitivity and Specificity values of PaO2 for detecting the presence of Hepatopulmonary Syndrome.

Correlation between reduction in microvascular transit time after superficial temporal artery-middle cerebral artery bypass surgery for moyamoya disease and the development of postoperative hyperperfusion syndrome.

OBJECTIVE Hyperperfusion syndrome (HPS) is a notable complication that causes various neurological symptoms after superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery for moyamoya disease (MMD). The authors used intraoperative indocyanine green (ICG) videoangiography to measure the change in microvascular transit time (MVTT) after bypass surgery. An analysis was then conducted to identify the correlation between change in MVTT and presence of postoperative HPS. METHODS This study included 105 hemispheres of 81 patients with MMD who underwent STA-MCA single bypass surgery between January 2010 and January 2015. Intraoperative ICG videoangiography was performed before and after bypass surgery. The MVTT was calculated from the ICG time intensity curve recorded in the pial arterioles and venules. Multivariate logistic regression analysis was conducted to test the effect of multiple variables, including the change in MVTT after bypass surgery, on postoperative HPS. RESULTS Postoperative HPS developed in 28 (26.7%) of the 105 hemispheres operated on. MVTT was reduced significantly after bypass surgery (prebypass 5.34 ± 2.00 sec vs postbypass 4.12 ± 1.60 sec; p < 0.001). The difference between prebypass and postbypass MVTT values, defined as ΔMVTT, was significantly greater in the HPS group than in the non-HPS group (2.55 ± 2.66 sec vs 0.75 ± 1.78 sec; p < 0.001). Receiver operating characteristic curve analysis revealed that the optimal cutoff point of ΔMVTT was 2.6 seconds (sensitivity 46.4% and specificity 85.7% as a predictor of postoperative HPS). A ΔMVTT > 2.6 seconds was an independent predictor of HPS in multivariate analysis (hazard ratio 4.88, 95% CI 1.76-13.57; p = 0.002). CONCLUSIONS MVTT in patients with MMD was reduced significantly after bypass surgery. Patients with a ΔMVTT > 2.6 seconds tended to develop postoperative HPS. Because ΔMVTT can be easily measured during surgery, it is a useful diagnostic tool for identifying patients at high risk for HPS after STA-MCA bypass surgery for MMD.