Perianal Infection Research Articles

Efficacy of radial incision combined with tunnel floating line drainage in the treatment of high posterior horseshoe anal fistula and perianal flora: Randomized control trial.

Due to the high prevalence of posterior horseshoe anal fistula and causing numerous complications, this study aimed to investigate the clinical effect of radial incision combined with tunnel floating line drainage (RCTD) and arc incision internal drainage in the treatment of the disease and the influence on perianal flora. Ninety-six subjects treated with high posterior horseshoe anal fistula were stochastically assigned to a joint group (RCTD), and control group (arc incision internal drainage). The operation-related conditions, complication rate, anal function, and recurrence rate of 6 months after operation were compared, and perianal secretions were collected before operation and 1 day after operation to detect the changes of microbial flora. After operation, it was corroborated notable difference between joint group and control group in operation time, intraoperative blood loss, wound healing time, visual analogue scale score 6 hours after operation and phase I cure rate. Chi square test analysis showed notable difference between control group (27.08%) and joint group (10.40%) in incidence of complications, in terms of number of pathogens detected around anus, significantly smaller of the incremental change for the joint subgroup versus the control subgroup 1 day after operation. RCTD can be the best choice for patients with high posterior horseshoe anal fistula. This operation method has the advantages of short operation time, less trauma, fewer complications, fast recovery of anal function, and can also reduce perianal pathogenic bacteria infection.

The effects of substituting cladribine for fludarabine on outcomes of a reduced intensity conditioning regimen.

e18518 Background: Drug shortages may be encountered especially in times of pandemics and war. The extrapolation of data focusing on different diseases may provide clinical clues for substituting two chemotherapeutic drugs of the same class. The substitution of cladribine for fludarabine in a reduced intensity conditioning (RIC) regimen composed of fludarabine, melphalan and total body irradiation (TBI) may yield similar side effect profile and outcomes. Methods: Consecutive patients undergoing an allogeneic stem cell transplant in our center between November 2019 to December 2022 were included. Within this period cladribine had to be substituted for fludarabine during a drug shortage. All patients received intravenous melphalan 75 mg/m2/day on day -2, and 200 cGy TBI on day -1. The regimen included either subcutaneous cladribine 10 mg/m2/day on days -5 to -2, or intravenous fludarabine 40 mg/m2/day on days -5 to -2. Graft versus host disease (GvHD) prophylaxis included a calcineurin inhibitor (CNI) + mycophenolate mofetil (MMF) for matched related donor transplants; and post-transplant cyclophosphamide + CNI + MMF for matched unrelated (MUD) and haploidentical donors. The distributions and medians of studied parameters in two cohorts were compared with non-parametric methods. Overall survival (OS), progression-free survival (PFS) and transplant-related mortality (TRM) were estimated by the Kaplan-Meier Method. The cut-off for statistical significance was defined as p<0.05. Results: A total of 70 patients (27 in cladribine and 43 in fludarabine cohort) were included. Median age was 59 (22 to 76) and 64.3% constituted males. Median follow-up was 10.2 months (0.1 to 44.7). Acute leukemia diagnosis, intermediate to high disease risk index (DRI) and intermediate to high Charlson comorbidity index (CCI) constituted 45.7%, 60.0% and 58.1% respectively. Haploidentical donors were used in 28.6%. The distribution of gender, diagnosis, DRI and CCI scores, donor type, total CD34 dose given, panel reactive antibody (PRA) positivity were similar. Median days to neutrophil engraftment was shorter with fludarabine (19 vs 16, p=0.01), however, median duration of in-unit stay was similar (27 vs 28 days, p=0.73). TRM, nausea and acute GvHD frequency was lower with cladribine (p=0.35, p=0.001 and p=0.02, respectively). Typhilitis and perianal infections were more common with cladribine (p=0.07 and p=0.04, respectively). OS and PFS were similar (p=0.81 and p=0.66, respectively). When cladribine was compared to fludarabine on day +90, OS was 78,0% (95% CI: 62.3-93.7) vs 65,0% (95% CI: 51.3-78.7); PFS was 70.0% (95% CI: 52.4-87.6) vs 65.0% (95% CI: 51.3-78.7); TRM was 19.0% (95% CI: 3.3-34.7) vs 24.0% (95% CI: 10.3-37.7). Conclusions: Cladribine may be safely constituted for cladribine in a RIC regimen and may yield similar, even some favorable, outcomes when compared to fludarabine.

Efficacy of surgical treatment of perianal infection in patients with hematological malignancy.

The efficacy of surgical intervention for perianal infection in patients with hematologic malignancies is not well established. Therefore, our study aimed to investigate the clinical efficacy and complications of surgical treatment of perianal infection in patients with hematologic malignancies. This retrospective study included patients with hematological malignancies who were diagnosed with perianal infections and treated at the China Aerospace Science & Industry Corporation 731 Hospital between 2018 and 2022. Patient characteristics, hematological data, surgical intervention, and complications, including recurrence and mortality, were analyzed. This study included 156 patients with leukemia aged 2 months to 71 years who were treated surgically for perianal infection, comprising 94 males and 62 females. Perianal infection included 36 cases of abscesses, 91 anal fistulas, and 29 anal fissures accompanied by infection. A total of 36 patients developed severe complications postoperatively, including 4 patients who died, 6 patients with severe incision bleeding, 18 patients with severe pain, 6 patients with sepsis, 12 patients who needed reoperation, 15 patients with hospitalization for more than 2 weeks, and 3 patients with anal stenosis; none of the patients developed anal incontinence. Additionally, risk factors for postoperative complications of perianal infection in patients with hematologic malignancies include leukopenia, agranulocytosis, thrombocytopenia, depth of abscess and not undergone an MRI. Surgical intervention may improve the prognosis of patients with perianal abscess formation, particularly in patients who show no improvement with medical therapy and those who develop perianal sepsis. Granulocytopenia and thrombocytopenia should be improved before surgery, which can significantly reduce postoperative complications. Although these findings are from a case series without a comparator, they may be of value to physicians because to the best of our knowledge, no randomized or prospective studies have been conducted on the management of perianal infections in patients with hematological malignancies.

Факторы риска развития рецидивов перианальных инфекционных осложнений у пациентов с опухолевыми заболеваниями системы крови: результаты одноцентрового проспективного исследования

Aim. To study risk factors for relapses of perianal infection (PI) in patients with hematological tumors.
 Materials & Methods. This single-center prospective clinical trial (2016–2020) enrolled all oncohematological patients at the National Research Center for Hematology who developed PI at various stages of chemotherapy. To assess the impact of some factors on relapsing perianal infectious complications, the distribution of clinical characteristics in groups of patients with single or multiple PI episodes was analyzed.
 Results. The trial addressed 158 PI episodes in 132 patients; there were 64 men and 68 women, the median age was 40 years (range 18–77 years). PI relapses were identified in 22 (16.67 %) patients, with a higher incidence in acute myeloid leukemia (AML) patients (63.64 %). Recurrent PI episodes were usually registered on program therapy of acute leukemias (73.08 %), more often at consolidation stage (38.46 %) than at other stages of treatment (17.42 %) (hazard ratio [HR] 2.96; 95% confidence interval [95% CI] 1.19–7.35; p < 0.031). With the follow-up of 360 days from the first episode, the probability of PI relapses was 16.2 %, and it was higher in AML patients (24.3 %). In non-remission AML patients having the first PI episode, the probability of PI relapses considerably increased and accounted for 52.6 %. In case of cryptogenic pararectal abscesses, it was 20 %, if solely abscess drainage was performed at the first stage. However, no relapses were registered after the surgical treatment of pararectal fistulas. The risk factors for recurrent PI, as was shown by univariate analysis, were AML diagnosis (HR 2.94; 95% CI 1.14–7.62; p < 0.032) and the lack of remission of hematological tumor by the time of the first PI episode (HR 2.98; 95% CI 1.13–7.90; p < 0.034). By multivariate analysis, the significant risk factor was non-remission AML diagnosis by the time of the first PI episode (HR 6.94; 95% CI 2.93–16.66; p < 0.0001).
 Conclusion. The significant risk factor for PI relapses is non-remission AML diagnosis by the time of the first infectious episode. This category of patients shows the maximal probability of relapsing perianal infectious complications, which is 52.6 %. To prevent PI relapses in patients with cryptogenic pararectal abscesses, abscess drainage should be combined with scheduled surgery of anal fistulas.

Risk factors for therapy failure after incision and drainage alone for perianal abscesses in children.

It is well known that recurrent perianal abscesses (PAs) and fistula-in-ano (FIA) are the main causes of therapy failure following incision and drainage (I&D) for PAs. But few studies have focused on the risk factors for therapy failure after I&D for PAs in children. In this study, we retrospectively examine the risk factors for therapy failure after I&D for PAs in children in a pediatric tertiary care institution. A retrospective review of all outpatient children with PA treated by I&D at Beijing Children's Hospital between January 2021 and December 2022 was performed. A follow-up was conducted in October 2023. Patients with other predisposing factors for perianal infection, such as inflammatory bowel disease, hematologic tumor, and anorectal surgery, were excluded from this study. Logistic regression yielding odds ratios (ORs) was used to assess the significance of variables for therapy failure. Of 160 children initially identified, follow-up was available for 146, with a total of 172 treatments. A total of 91% of children were male. The median (interquartile range) age at I&D was 2 (1, 15) months. The median follow-up duration was 20 (14, 25) months. Therapy failure occurred in 25 (15%) treatments performed for the prevention of recurrence of PA and in 35 (20%) treatments for the prevention of development of FIA. In the univariate analysis, a history of PA (P = 0.001), history of I&D (P = 0.014), and multilocal occurrence (P = 0.003) were associated with therapy failure. A sitz bath after I&D (P = 0.016) and regular cleaning of the wound after I&D (P = 0.024) were associated with therapy success. In the multivariate analysis, a history of PA (P = 0.015, OR = 3.374) and multilocal occurrence (P = 0.012, OR = 4.649) were independently associated with therapy failure. Regular cleaning of the wound (P = 0.017, OR = 0.341) and sitz bath (P = 0.001, OR = 0.128) after I&D were independently associated with therapy success. A history of PA and multilocal occurrence were predictor factors for therapy failure before I&D. Regular cleaning of the wound and sitz bath after I&D were protective factors for therapy success. Therefore, regular cleaning of the wound and sitz bath after I&D should be emphasized in all children with PAs, especially in those with a history of PA and multilocal occurrence.

Prevalence and Associated Factors of Hemorrhoids and Other Perianal Complications During the Puerperium Among Mothers Who Gave Birth at Debre Tabor Referral Hospital, Debre Tabor, Ethiopia, 2022

Puerperium is defined as the period of six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition. Perianal problems, including constipation, hemorrhoids, and fissures, are among the most common complications among women during the puerperium, observed in about 30 to 50 percent of women. Considering this great prevalence and the paucity of similar research in Ethiopia, this study was done to assess the prevalence of perianal problems during the puerperium and the risk factors associated with them. METHODS: An institution-based cross-sectional study was conducted from February 1 to April 30, 2022. Quota sampling technique was used to select a total of 191 participants. The data were collected and then entered using EPI DATA version 3.1 and exported to STATA 14 for analysis. Bivariable and multivariable logistic regression analyses were performed. Adjusted odds ratio (AOR) with 95% confidence interval was used as a measure of association. Variables having a P-value < 0.05 from the multivariable analysis were considered to have a significant association with the outcome. RESULTS: The total prevalence of all the perianal problems in the puerperium encountered in this study was 22.5% (43 mothers). The perianal problems encountered were fissure [9.4%], followed by hemorrhoids [7.3%], peri-anal episiotomy infections (4.2%), and peri-anal tears (1.6%). Comparative analysis showed that positive family history, past history of perianal diseases, and prolonged second stage of labor (>50 minutes) showed a higher prevalence in the perianal disease group as compared to the healthy group. A statistically significant relationship was observed between the prevalence of hemorrhoids and a past history of any perianal disease [p=0.04]. A statistically significant relationship was observed between the prevalence of hemorrhoids and parity [p=0.02]. There was also a statistically significant relationship between constipation during pregnancy and the development of hemorrhoids [p=0.01]. CONCLUSION: Anal fissure, hemorrhoids, and perianal episiotomy infections are the most common perianal problems in the postpartum period, causing a significant reduction in the quality of life of those afflicted with them.

Post-Chemotherapy Clinical Perianal Infection Features in Patients with Acute Leukemia

Objective: This study aims to examine the incidence of post-chemotherapy perianal infection and its influencing factors in patients with acute leukemia.<br>Methods: A total of 243 patients with acute leukemia who underwent chemotherapy in the Three Gorges Hospital affiliated to Chongqing University, China, between January 2019 and December 2020 were selected as study subjects. In the present retrospective study, patients with post-chemotherapy perianal infection were monitored, and the perianal infection rate and clinical features of perianal infection were determined. Categorical variables were compared using the Chi-square test, and the influencing factors of post-chemotherapy perianal infection in patients with acute leukemia were evaluated using logistic analysis.<br>Results: A total of 24 patients (9.88%) with acute leukemia suffered post-chemotherapy perianal infection. Age, basic perianal disease (hemorrhoids) history, constipation, diarrhea, duration of agranulocytosis, and length of hospital stay were compared among the patients. Perianal disease classification, perianal ultrasound, colonoscopy, postoperative pathology, and other clinical data were compared and discussed in relation to the occurrence and development of the disease. The results showed that there were no significant differences in perianal infection degrees between genders and among different types of leukemia (p > 0.05). There were no statistically significant differences in age, pain score, minimum white blood cell count, deficiency duration, and length of hospital stay among patients with different degrees of infection. The Spearman rank correlation test showed that the perianal infection degree was positively correlated with the highest hypersensitive C-reactive protein (hs-CRP) level (p < 0.05). The difference was statistically significant; the higher the maximum hs-CRP/procalcitonin levels, the more serious the perianal infection.<br>Conclusions: Perianal infections are common in the procession of chemotherapy or myelosuppression. This is worthy of clinical recognition. Early recognition of perianal infection and the strengthening of infection risk factor control may be beneficial to improving the subjective feelings of patients with acute leukemia undergoing chemotherapy.

Clinical and genomic characterization of carbapenem-resistant Enterobacterales bloodstream infections in patients with hematologic malignancies.

Carbapenem-resistant Enterobacterales (CRE) bloodstream infections (BSIs) pose a significant risk to patients with hematologic malignancies, yet the distinct features and outcomes of these infections are not thoroughly understood. This retrospective study examined the characteristics and clinical outcomes of patients with Enterobacterales BSIs at the Hematology Department of Fujian Medical University Union Hospital from 2018 to 2022. Whole-genome sequencing was conducted on 45 consecutive CRE BSI isolates during this period. A total of 301 patients with Enterobacterales BSIs were included, with 65 (21.6%) cases of CRE and 236 (78.4%) cases of carbapenem-susceptible Enterobacterales (CSE). CRE infections accounted for 16.9% to 26.9% of all Enterobacterales BSIs, and carbapenem-resistant Klebsiella pneumoniae (CRKP) was the predominant strain. The most frequent sequence type (ST) and carbapenemase among CRKP were ST11 (68.6%) and blaKPC-2 (80.0%), respectively. Perianal infections, multiple infection foci, and a history of multiple hospitalizations, ICU stays, and prior CRE infections were identified as risk factors for CRE BSIs. Patients in the CRE group experienced significantly higher proportions of infection-related septic shock (43.1% vs. 19.9%, P < 0.0003) and 30-day all-cause mortality (56.9% vs. 24.6%, P < 0.0001) compared to those in the CSE group. Patient's age and disease subtypes, strain subtypes, and antimicrobial treatment regimens significantly influenced survival in patients with CRE BSIs. CRE BSIs are a frequent complication in patients with hematological malignancies undergoing treatment and are associated with poor survival rates. A comprehensive understanding of risk factors and ongoing surveillance of prevalent strains are essential for the effective management of these infections.

Good Survival of CAR-T Cell Therapy Bridging to Allo-HSCT for Relapsed/Refractory Ph-Positive B-Cell Acute Lymphoblastic Leukemia

Aims: The addition of tyrosine kinase inhibitors (TKIs) has significantly improved the prognosis of Ph-positive (Ph+) B-cell acute lymphoblastic leukemia (B-ALL). However, there are still a certain proportion of patients resistant to conventional means or relapse after treatment. In current study, the efficacy and safety of CAR-T bridging to allo-HSCT for patients with relapsed/refractory (r/r) Ph+ B-ALL were evaluated. Methods: Between November 2018 and July 2023, 29 consecutive patients with r/r Ph+ B-ALL were included. The median age was 32(2-61) years old, 17 male and 12 female. All patients were not in CR MRD-（complete remission with negative BCR/ABL fusion genes detected by real-time PCR）status, 11 cases in CR MRD+ and 18 cases in NR (not remission). 10 patients had clear extramedullary lesions. 15 patients had mutations in the coding region of the ABL1 gene T315I kinase. 9 patients had a history of allo-HSCT. After CART treatment, the patient sequentially enters the transplant procedure. 5 patients received allo-HSCT from sibling HLA matched donors, 19 patients from haploidentical donors and 5 patients from unrelated donors. Myeloablative conditioning regimens with total body irradiation (fractionated, total 10 Gy) /etoposide (200mg/m 2 x 3) /fludarabine (30mg/m 2 x 5) or cyclophosphamide (1.8g/m 2 x 2) /rabbit anti-T-cell globulin were used. The infusion count of MNC cells was 4.35-15.36×10 8/kg and CD34+ cells was 2.57-8.5×10 6/kg. Cyclosporine, mycophenolate mofetil and short-term methotrexate were employed for graft-versus-host disease (GVHD) prophylaxis. All patients received sensitive TKIs up to 2 years post-transplantation. Results: After CART therapy, 7 of the 11 patients with CR MRD+ status obtained CR MRD-, and 4 still in CR MRD+. 11 of 18 patients with NR status obtained CR MRD-, 6 patients obtained CR MRD+ , and 1 case still in NR. In the allo-HSCT procedure, all patients achieved durable engraftment. 5 patients developed mild aGVHD, 4 patients developed severe aGVHD, 1 patient developed mild cGVHD, and 6 patients developed severe cGVHD. All of them were resolved with immune-suppressants except 1 patient died. CMV reactivation occurred in 14 patients and EBV reactivation in 1 patient. 6 patients developed hemorrhagic cystitis. 14 patients developed definite organ infections, of which 11 were pulmonary infections, the others were intestinal infections, perianal infections, urinary tract infections, and sepsis. 5 patients were infected by the COVID-19 virus during epidemic, and 1 of them progressed to pneumonia. The median follow-up time was 21 (2-46) months, 23 patients are alive to date, of which 22 patients have no leukemia and 1 patient has recurrent molecular MRD and still receiving treatment. The 2 years overall survival (OS) and leukemia-free survival (LFS) both reached 78.6% (95%CI 0.583-0.898). Among the 6 deceased patients, 1 patient with pre-HSCT NR did not achieve remission after transplantation and died of severe aGVHD, 2 patients died of recurrent leukemia after transplantation, and 3 patients died of severe infection. The non-relapse mortality (NRM) was 13.8% (4/29). After treatment, of the 10 patients with extramedullary lesions, 8 (8/10) were living without leukemia. Among the 15 patients with ABL1 gene T315I kinase region mutation, 13 (13/15) were leukemia-free survival. Of the 9 patients with a history of allo-HSCT, 6 (6/9) survived without leukemia. Among the 10 patients with pre-transplantation CR MRD+ status, 8 (8/10) were leukemia-free after transplantation, the 2 years LFS was 80% (95%CI 0.527-0.869). Conclusion: Our results indicate that CAR-T bridging to allo-HSCT is safe and effective for patients with r/r ph+ ALL. The 2 years OS and LFS both reach to 78.6%. The risks associated with treatment are acceptable. Even for patients with extramedullary lesions, patients with mutations in the T315I kinase region of ABL1 gene, and patients with a history of allo-HSCT, good results can be achieved, indicating that CART bridging to allo-HSCT appear to overcome above adverse prognostic factors. Although a proportion of Ph+ALL patients (this proportion seems to be higher than Ph-ALL) still can not achieve CR MRD- after CART treatment, this does not prevent patients from transplantation carrying MRD and achieving good results (2 years LFS is 80%). Therefore, in clinical practice, if it is very difficult for patients to obtain CR MRD-, allo-HSCT is also recommended.

Venetoclax Combined with Azacitidine Was Effective and Safe for Relapsed/Refractory T-Cell Acute Lymphoblastic Leukemia/ Lymphoblastic Lymphoma: Preliminary Results of a Phase 2, Multicenter Trial

Introduction: Relapsed/refractory T-cell acute lymphoblastic leukemia/lymphoblastic lymphoma (R/R T-ALL/LBL) is highly heterogeneous. The available salvage treatment options for relapsed patients showed remission rates of less than 50% and a 5-year overall survival (OS) rate of less than 25%. Venetoclax, a Bcl-2 inhibitor, in combination with azacitidine, has demonstrated a high remission rate in 5 patients with R/R T-ALL/LBL in our previous report. Here, we report the interim analysis of a phase 2 study (NCT05149378) for the treatment of venetoclax combined with azacitidine for R/R T-ALL/LBL. Methods: From November 2021 to May 2023, a total of 18 R/R T-ALL/LBL patients were enrolled in the study. Among them, 11 were male and 7 were female. These patients were from seven hospitals, including the central hospital of the First Affiliated Hospital of Soochow University. All patients received salvage treatment with venetoclax (orally, 100mg on day 1, 200mg on day 2, and 400mg on days 3-21) and azacitidine（75mg/m 2/d on days 1-7, subcutaneously). Bone marrow evaluation was performed after the blood cell count recovery or within 42 days since the initiation of the treatment. Results: Among the 18 patients enrolled, 8 were diagnosed with T-ALL, 7 with ETP-ALL, and 3 with T-LBL (Table). 5/18 patients were relapsed T-ALL/LBL, 13/18 patients were refractory to previous treatments. The median age of the patients was 39 years (range: 30-53). After 1-2 courses of venetoclax in combination with azacitidine regimen. 4 (22.2%) achieved CR, 1 patient (5.6%) achieved CRh, 9 (50.0%) patients achieved CRi and 2 (11.1%) achieved MLFS. The overall response rate was 88.9%. With a median follow-up time of 24.1 months (95% CI: 6.8-41.4), the estimated median OS was 24.1 months (95% CI: 6.8-41.4) (Figure a) and the median relapse-free survival was 14.0 (95% CI: 3.8-24.2) months (Figure b). After the treatment, 12/18 (66.7%) patients underwent allogeneic hematopoietic stem cell transplantation. Five patients experienced relapse between 6 to 19 months after the venetoclax and azacitidine treatment. Four patients died because of relapse after the regimen, two patients died because of COVID-19. Grade 3 or higher treatment-related hematologic AE included neutropenia (15/18, 83.3%), anemia (6/18, 33.3%), and thrombocytopenia (4/18, 22.2%). Treatment-related non-hematologic AE included infections (6/18, 33.3%. 4 patients developed pneumonia, 1 patient had perianal infection, 1 patient developed sepsis), elevation of ALT and AST (5/18, 27.8%), and renal function impairment (2/18, 11.1%). There was no other grade 3 or higher non-hematologic AE and no treatment-related death was observed. Conclusion: Our results showed that venetoclax in combination with azacitidine was an effective salvage regimen for R/R T-ALL/LBL patients. The benefit of this regimen for distinct cytogenetic groups in R/R T-ALL/LBL needs to be analyzed in more cases.

Granulocyte Transfusion Therapy as a Bridge to Hematopoietic Stem Cell Transplant in a Child with Aplastic Anemia and Refractory Perirectal Abscess

Granulocyte Transfusion Therapy as a Bridge to Hematopoietic Stem Cell Transplant in a Child with Aplastic Anemia and Refractory Perirectal Abscess

Construction and validation of a risk prediction model for perianal infection in patients with haematological malignancies during chemotherapy: a prospective study in a tertiary hospital in China

ObjectivesPerianal infection is a serious complication in patients undergoing chemotherapy for haematological malignancies. Therefore, we aimed to develop a predictive model to help medical staff promptly screen patients at a...

Precise Nursing of Six Patients Who Underwent Second Allogeneic Hematopoietic Stem Cell Transplantation

This study aimed to summarize the experience of precise nursing in 6 patients who experienced failed allogeneic hematopoietic stem cell transplantations (allo-HSCTs) that underwent second allo-HSCT salvage treatment. The key points of nursing care included strictly implementing infection prevention and control measures to prevent secondary infections, precise symptom management to improve the graft survival rate of patients, formulating reasonable nutrition programs to meet their requirements, and paying attention to the psychological care of patients to enhance their self-confidence in overcoming diseases. The patients developed different degrees of complications in the process of transplantation. During the transplantation, 2 patients had oral mucositis, 2 had hemorrhagic cystitis, 3 had a perianal infection, and one had lower gastrointestinal bleeding. After careful treatment and nursing, the neutrophils transplanted in the 6 patients were alive at a median of 16.5 (13-20) days after the second allo-HSCT, and the patients were successfully transferred out of the laminar flow chamber.

Surveillance of noninvasive group A Streptococcus infections in French ambulatory pediatrics before and during the COVID-19 pandemic: a prospective multicenter study from 2018-2022

We evaluated the burden of noninvasive group A Streptococcus (GAS) infections in ambulatory pediatrics before and during the COVID-19 pandemic in France. We analyzed data from a national network of ambulatory pediatricians between 2018 and 2022. Clinicians evaluating children ≤15 years old for tonsillopharyngitis, perianal infections, paronychia/blistering dactylitis, and scarlet fever were invited to perform a rapid antigen detection test (RADT) for GAS. Monthly incidence of noninvasive GAS infections per 10,000 visits was modeled using time series analysis, considering two breakpoints: March 2020 (first national lockdown) and March 2022 (end of mandatory mask-wearing in schools). Over the study period, 125 pediatricians recorded 271,084 infectious episodes. GAS-related illnesses represented 4.3% of all infections. In March 2020, the incidence of GAS diseases decreased by 84.5% (P <0.001), with no significant trend until March 2022. After March 2022, the incidence significantly increased (+23.8% per month, P <0.001), with similar patterns across all monitored GAS-related diseases. By using routine clinical data and RADTs, we have monitored changes in the incidence of noninvasive GAS infections in ambulatory pediatrics. COVID-19 mitigation measures have had a major impact on the epidemiology of noninvasive GAS infections, but their relaxation was followed by a surge above baseline levels.

Perianal Complications in Puerperium and Associated Risk Factors

Abstract Introduction Puerperium is defined as the period of about 6 weeks after childbirth during which the mother's reproductive organs return to their original nonpregnant condition. Perianal problems, including constipation, hemorrhoids, and fissure, are among the most common digestive complications among women in puerperium, observed in about 30 to 50 percent of women. Considering this great prevalence and the paucity of similar research in this aspect in an Indian population, the present study was done to assess the prevalence of perianal problems seen in puerperium and the risk factors associated with it. Methods This was a prospective observational cohort study done over the span of 3 years on 902 puerperal women. A self-structured questionnaire covered detailed history and per-rectal and proctoscopy examination. Patients were followed up telephonically for regression of perianal problems post management. Results The total prevalence of all the perianal problems in puerperium encountered in the present study, out of 902 subjects, was 36.3% (327 subjects). The perianal problems encountered were fissure in 185 patients (20.5%) followed by hemorrhoids in 110 patients (12.2%), perianal episiotomy infections in 25 patients (2.8%), and perineal tears in 7 patients (0.8%). On comparative analysis, positive family history, macrosomia, past history of perianal diseases, and second stage of labour &gt; 50 minutes showed a higher prevalence in the perianal disease group as compared with the healthy group. Out of these, positive family history of perianal diseases (p = 0.015) and past history of perianal diseases (p = 0.016) were statistically significant. The percentage of multipara with hemorrhoids was more when compared to primipara (p = 0.01), patients who had a past history of any perianal disease have a higher chance of hemorrhoids during puerperium (p = 0.00). Patients with constipation in pregnancy have higher chance of hemorrhoids in pregnancy (p = 0.00). Patients who had a past history of any perianal disease had higher chance of fissure during puerperium (p = 0.00). A total of 27.74% of the study subjects with macrosomic babies had fissure in their puerperal period which on comparison with patients with non macrosomic babies was only 19.22%, which was statistically significant (p = 0.02). Conclusion Constipation, hemorrhoids, and anal fissures are the most common perianal problems in postpartum period causing significant reduction in the quality of life of those afflicted with them.

Analgesic effect of subcutaneous injection of different concentrations of methylene blue after hemorrhoidectomy: A retrospective study.

Subcutaneous injection of methylene blue around the anus may help reduce postoperative pain. However, the concentration of methylene blue is still controversial. Therefore, Our study aims to investigate the efficacy and safety of different methylene blue injected concentrations subcutaneously in pain treatment after hemorrhoidectomy. A total of 180 consecutive patients with grade III or IV hemorrhoids from March 2020 to December 2021 were reviewed. All patients underwent hemorrhoidectomy under spinal anesthesia and were divided into three groups. Group A received subcutaneous injection of 0.1% methylene blue after hemorrhoidectomy, group B received subcutaneous injection of 0.2% methylene blue, and Group C did not received subcutaneous injection of methylene blue. The primary outcome measures were the visual analog scale (VAS) pain score on postoperative days 1, 2, 3, 7, 14, and total analgesic consumption within 14 days. Secondary outcomes were complications after hemorrhoidectomy, including acute urinary retention, secondary bleeding, perianal incision edema, and perianal skin infection, and the Wexner scores used to assess the level of anal incontinence at one and three months after surgery. There was no significant difference among three groups in sex, age, course of the disease, hemorrhoid grade and the number of incisions, and there was no significant difference in the volume of methylene blue injected between group A and group B. The VAS pain score and total analgesics consumption within 14 days in group A and group B were significantly lower than those in group C, but the differences between group A and group B were not statistically significant. The Wexner scores of group B were significantly higher than those of group A and group C one month after the operation, but the differences between group A and group C were not statistically significant. In addition, the Wexner score among three groups decreased to zero at three months after operation. There was no significant difference in the incidence of other complications among three groups. The perianal injection of 0.1% methylene blue and 0.2% methylene blue have a similar analgesic effect in pain treatment after hemorrhoidectomy, but 0.1% methylene blue has higher safety.

Characteristics of Fournier gangrene and evaluation of the effects of negative-pressure wound therapy.

Fournier gangrene (FG) is a life-threatening disease affecting the soft tissues of the genital, perineal, and perianal regions. This retrospective study aimed to summarize the characteristics of FG and evaluate the effects of negative-pressure wound therapy (NPWT). We analyzed clinical data of 36 patients with FG admitted to our department. Thirty-four cases had perianal and external genital infections, and the other two had secondary infection of the urinary fistula after trauma and retroperitoneal abscess, respectively. Monomicrobial, polymicrobial, culture-negative, and fungal infections were identified in 16, 17, 2, and 1 cases, respectively. Escherichia coli, Enterococcus faecalis, Enterococcus faecium, Klebsiella pneumoniae, and Staphylococcus haemolyticus were the most common pathogens. The mortality rate was 8%. Twenty-seven and nine patients were treated with NPWT (group A) and conventional dressing (group B), respectively. The length of stay was 38.0 ± 16.1 and 51.0 ± 17.3 days, number of operations were 3 (3,6) and 13 (4,17), and wound healing times were 39.2 ± 18.1 and 66.5 ± 17.1 days in groups A and B, respectively. Taken together, clinicians should always consider the possibility of perianal or external genital infections progressing to FG in the daily work, especially for patients with diabetes mellitus. Enterobacteriaceae, Enterococcus, and Staphylococcus haemolyticus are the most common causative pathogens, and NPWT is an effective adjuvant therapy for wound management with fewer operations and a shorter wound healing time.

S69 Case Report: Enterovesicle Fistulas and Their Presentation in Three Adolescent Males With Crohn's Disease

Case: Background: Enterovesicle fistulas (EVF) in the setting of Crohn’s disease (CD) are uncommon. The aim of this poster is to shed light on the diagnosis and management (medical vs surgical) of EVF in pediatric populations. Methods: This poster compares 3 cases of adolescent males with Crohn's disease, their continued workup, and the difference in disease course in relation to the development of EVF. Results: Case 1: A 12-year-old male with known severe ileocolonic CD diagnosed at age 8, and a history of perianal and intra-abdominal abscesses and perianal fistula experienced recurrent urinary tract infection (UTI) 2 years into his diagnosis. A urine sample revealed stool, and magnetic resonance imaging (MRI) confirmed EVF. Exploratory laparotomy revealed inflamed and structured distal ileum with pre-stenotic dilation of proximal bowel, as well as the EVF. After surgical takedown, ileocectomy, and diverting ileostomy, he was started on infliximab. He has been on infliximab for 28 months with normalization C-reactive protein, normal linear growth curve, and no further episodes of structuring or penetrating CD. Cast 2: After years abdominal pain and growth failure a 16-year-old male (now 17) was diagnosed with Crohn's ileitis. After starting Infliximab, he began complaining of sediment and pneumaturia, which was confirmed on urinalysis (UA). He was taken to surgery for diagnostic laparoscopy where his cecum was found to be adherent to the bladder. Distal loop ileostomy was created. He is currently being treated with infliximab and doing well 1-month post-operatively. Case 3: A 22-year-old male was diagnosed with Crohn’s ileitis at age 13, after presenting with abdominal pain and weight loss. Before beginning medical therapy, he experienced dysuria and pneumaturia with visible stool in his urine sample. EVF was not seen on abdominal Computed Tomography (CT) scan. His EVF was confirmed on exploratory laparotomy, and he underwent EVF take-down, ileocecectomy, and diverting ileostomy, with subsequent successful ileostomy take-down. He was started on thiopurine post-operatively and has remained in remission on therapy for 9 years without no further disease exacerbations. Conclusions: The incidence of EVF among adults with CD ranges from 2% to 5%, although little is known about pediatric patients with EVF. In fact, only 2 case reports in children exist. EVF can be the presenting symptom of CD, or patients with known CD can present with recurrent UTI leading to diagnosis. The distinct symptoms of EVF, dysuria, pneumaturia and fecouria, make it easy to diagnose with UA and confirmatory cross-sectional imaging, although little is known about common sites of connection between the bladder fistula in children and how this affects presentation and management (10). In our 3 cases, patients received surgical intervention followed by aggressive medical management. With the advent and improvement of immunotherapy medications, research in adults has shown that EVF without severe complicating CD can sometimes be treated with medical therapy alone and experience EVF resolution (2,6-9). There is no clear consensus on clinical criteria for medical vs surgical intervention (7,8) so future studies in this area are needed.

Response to Hypomethylating Agents Plus Venetoclax in Patients with Acute Myeloid Leukemia and Myelodysplastic Syndrome: Real World Data from a Developing Country

Background: Myelodysplastic syndrome (MDS) is a pre-malignant condition characterized by ineffective hematopoiesis, cytopenias and potential to transform into acute leukemia. Acute myeloid leukemia (AML) is a hematological malignancy deriving from myeloid progenitor cells. About one quarter of patients fail to respond to initial therapy (refractory AML). In addition, around 50% of initial responders relapse after a transient remission (relapsed AML). Commonly used salvage chemotherapy regimens include FLAG, FLAG-Ida, HIDAC and Hypomethylating agents (HMA) with or without Venetoclax. In patients who are ineligible for transplant or with poor functional status and in relapsed/refractory cases, treatment options are minimal. However recent data from Western countries has shown promising results with HMA plus Venetoclax in such patients. No such data is available from Pakistan. Objectives: To assess response of HMA plus Venetoclax in patients with AML and MDS treated at Armed Forces Bone Marrow Transplant Center, Rawalpindi, Pakistan. Methods: Study design: Single arm observational prospective study Research Setting: Armed Forces Bone Marrow Transplant Center, Rawalpindi, Pakistan. Study population: Cases included in study were patients of AML and MDS who received HMA plus Venetoclax. A total of 35 patients (25 AML, 10 MDS) were found eligible and included in the final analysis. The primary outcome measured was response to HMA plus Venetoclax. Results: Out of 25 AML patients 17 (68%) were male and 8 (32%) were female. Median age of patients was 44 (range 20-67). Six (24%) patients had AML MRC, 18 (72%) had AML NOS which included 2 (8%) AML-M0, 1 (4%) AML-M1, 9 (36%) AML-M2, 3 (12%) AML-M4 and 3 (12%) patients with AML-M5 while other 3 patients included 1 (4%) patient each of t-AML and AML transformed from Fanconi anemia and aplastic anemia. One (4%) AML-M2 patient had Monosomy 7 and 1 (4%) AML-M5 had trisomy 8. Three (12%), 16 (64%) and 6 (24%) patients were categorized into favorable, intermediate and high risk respectively. Nine (36%) had relapsed disease including 3 (12%) who had relapsed after allogenic HSCT, 8 (32%) had refractory disease while 7 (28%) were unfit for intensive chemotherapy due to advanced age or poor functional status. Median number of HMA+ Venetoclax cycles given were 3 (range 1-16). Overall response rate (ORR) was 44% (n=11), including 9 (36%) patients with CR and 1 (4%) with CRi. One (4%) patient had partial response (PR). Fourteen (56%) patients were non-responders. Of the 10 patients who responded, 6 (24%) achieved remission after 2 cycles while other 4 achieved remission, 1 (4%) patient each, after 1, 3, 5 and 6 cycles. Two (8%) patients underwent allogenic HSCT after achieving remission, including 1 (4%) who had relapsed after first HSCT and underwent second HSCT after achieving CR with HMA+Venetoclax. Out of 10 MDS patients 8 (80%) were male and 2 (20%) were female. Median age of patients was 51 (range 29-71). Two (25%) patients had MDS-MLD, 6 (60%) MDS-EB2 and 2 (20%) had fibrotic MDS. One (10%), 7 (70%) and 2 (20%) patients had intermediate, high and very high risk disease (as per R-IPSS score) respectively. One (10%) patient had relapsed after allogenic HSCT. Median no of cycles of HMA+Venetoclax given were 2 (range 1-6). Three (30%) patients achieved CR (after 2 cycles each), 2 (20%) had stable disease and 5 (50%) patients were non-responders. Two (20%) patients underwent allogenic HSCT after receiving HMA+Venetoclax (Table:1) Common side effects noted were prolonged cytopenias, febrile neutropenia and infections (cellulitis, perianal infections and fungal infections). No treatment related mortality was noted. Conclusion: HMA plus Venetoclax is effective treatment regimen in relapsed/ refractory AML and MDS, however our population shows inferior results as compared to Western population and further large randomized controlled trials are needed to validate this observation. Key Words: Relapsed AML, refractory AML, MDS, salvage chemotherapy, Hypomethylating agents, Venetoclax Research funding: None Word count: 691 Presentation type: Oral Category: Acute Leukemia/ Myelodysplastic syndrome Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Successful Reconstruction of a Defect Secondary to an Intersphincteric Abscess with Fournier’s Gangrene Using a Perforator-based Island Flap: A Case Report

Fournier’s gangrene, a soft tissue infection which is aggressive and sometimes lethal, often passes through deep fascial planes of the penis, scrotum, perineum, and lower abdomen; however, it rarely extends upward into the high intermuscular plane. We managed a rare case of Fournier’s gangrene with a high intersphincteric abscess from a perianal infection that resulted in a large defect in the anus and inferior aspect of the scrotum. A perforator-based island flap for the post-debridement defect was performed successfully. The perforator was selected near the defect along the lateral sacral border; the border of the flap design was adjacent to the defect, thus providing a sufficient angle of rotation near the pedicle with minimal dissection. Remnant undissected tissues around the pedicle prevented postoperative vascular complications. Additionally, the distal part of the flap design was elongated to the gluteal sulcus to be harvested as a very thin flap. This study suggests a perforator-based island flap as a secure and convenient option for covering a large defect involving the perianal region and inferior aspect of the scrotum.