Risk Of Surgical Intervention Research Articles

Long-term follow-up of otitis media with effusion in neonatal hearing screening

ObjectivesIncreased neonatal referral rate of conductive hearing loss (CHL) related to otitis media with effusion (OME) following universal neonatal hearing screening (UNHS) may cause an unnecessary clinical, emotional, and financial burden. This study analyzes the long-term, audiological, and medical characteristics of CHL associated with OME in neonates in order to establish a standardized protocol following technology-driven improvements in detection and referral rates in UNHS. MethodsA retrospective study of all neonates with OME-related CHL referred to the University Hospital of Leuven (Belgium) after failing UNHS with the MAICO devices between January 1, 2013 and December 31, 2021 was performed. Follow-up consultations, auditory tests, referral side, birth month, hearing loss degree, underlying pathologies and risk factors, time to normalization, and need for ventilation tubes were assessed. ResultsThe incidence of CHL related to OME was stable between 2013 and 2021. Of all referred infants with OME, 52.3 % demonstrated spontaneous recovery. The average time to hearing normalization was significantly longer in children with underlying congenital pathologies compared to those without. Moreover, 74.4 % of these children received ventilation tubes compared to 32.0 % of children without underlying pathologies. No correlation was found between the incidence of OME-related CHL with either a hearing loss degree, admission to neonatal intensive care, or history of a nasogastric feeding tube. ConclusionsIn children who failed UNHS due to OME, hearing recovers spontaneously without surgical intervention in 2/3 of the infants without underlying conditions within one year. In children with underlying congenital disorders, the time to hearing recovery is longer and the risk for surgical intervention is higher, underlining the need for implementing a UNHS standardized protocol.

IMG-07. PEDIATRIC CRANIAL INCIDENTALOMAS: A SYSTEMATIC REVIEW UTILIZING MACHINE LEARNING

Abstract BACKGROUND The use of diagnostic neuroimaging in the care of pediatric patients continues to increase, leading to a rise in incidentally discovered lesions. The understanding of appropriate assessment and management of these findings is critical to providing comprehensive and timely care. This review aims to analyze the current literature to characterize diagnostic and prognostic characteristics of incidentally found brain tumors in pediatric patients. METHODS Using the guidelines under the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), Pubmed and Medline (NCBI) databases were searched using selected keyword combinations and machine learning-assisted software. Case reports, case series, and retrospective cohort studies published up to December 2023 were included. RESULTS A total of 20 studies encompassing 627 patients were included in the review. The most common indications for imaging were headache (204; 33%), seizures (96; 15%), and trauma (78; 12%). Of studies providing information regarding localization, lesions were found in the supratentorial region in 327 (52%) cases and infratentorial region in 190 (30%). Of studies reporting imaging characteristics, T1 hypointensity (183/302; 61%), T2 hyperintensity (410/497; 82%), and no contrast enhancement (58/97; 60%) were the most common findings. Four hundred and thirty (68%) patients were observed after diagnosis, 83 (13%) patients underwent surgical intervention at diagnosis, and 40 (6%) patients underwent surgery after observation. Of 91 patients with histopathology data available, pilocytic astrocytoma (19; 21%) was most commonly reported. CONCLUSION In this study, we provide a review of diagnostic characteristics of incidentally discovered brain tumors in the pediatric population. Management of such lesions has changed greatly over the past several decades, and risks of surgical intervention should be weighed against a more conservative management and interval monitoring approach. These results may help guide discussions regarding disclosure of findings and recommendations for additional clinical management.

Pheochromocytoma in combination with severe aortic insufficiency: clinical case

Pheochromocytoma is a rare neuroendocrine tumor of the adrenal medulla with widespread cardiac complications. Dilation of the heart chambers can cause valve defects. At the same time, severe cardiac comorbid conditions that complicate the choice of treatment tactics for patients are not sufficiently described in the literature. A clinical case of pheochromocytoma in combination with severe aortic insufficiency in a man admitted to the endocrinology department is presented. In conditions of aortic insufficiency, the risk of surgical intervention is extremely high. After a thorough analysis of clinical and laboratory-instrumental data, the patient was recommended to have a right-sided laparoscopic adrenalectomy.

Beware the Boxer's Fracture Imposter: Where Does the Metaphysis End and the Diaphysis Begin?

Introduction: Fractures of the fifth metacarpal are a common injury. In children, they are often stable and heal uneventfully, including after closed reduction. Fractures of the metacarpal diaphysis, conversely, tend to be unstable and may require surgical intervention. It is unclear at what point fractures of the fifth metacarpal fracture should be considered unstable. We identify the location at which a fifth metacarpal fracture is at risk for surgical intervention. Methods: A two-year retrospective cohort analysis of all children (age ≤18) with fifth metacarpal fractures presenting to a Pediatric Plastic Surgery clinic was performed. Clinical and radiographical data were acquired from electronic medical records. Fracture location and fracture angulation were measured, descriptive statistics were performed, and multivariable logistic regression was used to identify predictors for surgery. Results: Ninety-eight patients met criteria for review. Mean patient age was 14.0 years (SD 2.2), and 95% were male. Forty-two (44.2%) patients underwent closed reduction, and 12 (12.2%) patients were recommended for surgery. Increased fracture angulation on initial lateral radiograph (OR: 1.08 (1.03-1.14 95% CI), p = 0.006) and more proximal fractures (OR: 0.92 (0.86-0.98 95% CI), p = 0.008) were identified as independent predictors for surgery. Fractures occurring proximal to 70% of metacarpal length resulted in accurate detection of those requiring surgery with 72.4% sensitivity, 75.3% specificity, 95.5% and 27.6% negative and positive predictive value, respectively. Conclusions: In pediatric fifth metacarpal fractures, increased fracture angulation and those occurring proximal to 70% of the metacarpal length were independent predictors for surgery.

P301 Distinct plasma proteomic biomarkers associate with disease progression in patients with Inflammatory Bowel Diseases

Abstract Background Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are characterized by complex pathophysiology, phenotypic heterogeneity and disease progression. Patients with IBD show distinct shifts in circulating inflammatory proteins, which may be suggestive of biological mechanisms behind clinical disease progression. Thus far, proteomics studies in IBD have primarily focused on changes in the plasma proteome at pre- and post-diagnostic stages, as well as its genetic and phenotypic determinants. However, studies focusing on proteomic biomarkers for predicting the risk of disease progression are lacking. Here we aimed to identify plasma proteomic biomarkers associated with disease progression in patients with IBD. Methods In this study, a total of 83 inflammation-related plasma proteins were quantified in a cohort of 452 patients with IBD (267 with CD, 185 with UC) who participated in the 1000IBD project and had available follow-up data. Proximity extension assay technology was leveraged to measure these proteins. Disease progression outcomes, including the development of intestinal stenosis, IBD-related surgical interventions, and extraintestinal manifestations (EIMs), were extracted from electronic health records. Logistic regression analyses and Cox proportional hazards regression models were used to investigate associations between plasma proteins and the risk of disease progression outcomes. Results During a median follow-up of 10.3 (interquartile range [IQR] 7.6-11.1) years, 63 (23.6%) patients with CD developed intestinal stenosis, 53 (19.9%) patients with CD and 14 (7.6%) patients with UC underwent IBD-related surgery, and 120 (44.9%) patients with CD and 45 (24.3%) patients with UC developed EIMs. On multivariable analysis, macrophage colony-stimulating factor-1 (CSF-1) was most strongly associated with the presence of stricturing disease (Montreal B2 phenotype) (odds ratio [OR] per doubling in protein level 4.5, 95%CI: 1.6-12.9, P=0.005) and with a shorter stenosis-free survival (hazard ratio [HR] per doubling 4.2, 95%CI: 1.5-11.6, P=0.006). Furthermore, interferon-gamma (IFN-γ) was most strongly associated with surgery in CD (OR per doubling 1.6, 95%CI: 1.2-2.2, P=0.003) and with shorter surgery-free survival in CD (HR per doubling 1.4, 95%CI: 1.2-1.7, P<0.001) in multivariable analysis. Conclusion This study highlights that disease progression in IBD is associated with elevated levels of specific inflammatory plasma proteins. Specifically, CSF-1 and IFN-γ show most promise as possible proteomic biomarkers for the future development of intestinal stenosis and the risk of surgical interventions in patients with CD, respectively.

Outcomes of Conservative Management of Postoperative Adhesive Small Bowel Obstruction among Yemeni Patients

Background: Adhesive small bowel obstruction (ASBO) is a surgical emergency and represents the leading cause of small bowel obstruction, accounting for 60–75% of cases. Conservative management is the main approach for treating ASBO in the absence of complications. Therefore, the present study aimed to assess the success rate, outcomes and complications of conservative management for ASBO in Yemen.
 Methods: A prospective, case-series study of 102 patients with ASBO was conducted at two tertiary care hospitals in Sana’a city, Yemen; namely, Al-Thawra Modern General Hospital and Kuwait University Hospital, in the period from January 2021 to January 2023. A structured data collection sheet was used to collect pre- and postoperative data, including demographic characteristics, history of previous surgery, type of surgery, time of presentation from initial symptoms, presenting symptoms, details of non-surgical management, success or failure of conservative treatment, intraoperative findings, complications during hospital stay, and condition at discharge. Data were then analyzed and presented using descriptive statistics.
 Results: Of 102 patients with ASBO, 69 patients (67.6%) responded well to conservative management and did not require surgical management, while conservative management failed and surgical intervention was indicated for 33 patients (32.4%). The condition of most patients undergoing conservative management (88.4%) improved within 1–2 days, while five patients (7.3%) improved within one day and three patients (4.3%) improved after three days. For patients who required surgical intervention, continuous abdominal compromise was observed in 31 patients (93.9%), fever in 23 patients (69.7%), tachycardia in 28 patients (84.8%), tenderness in 31 patients (93.9%), and leukocytosis in 13 patients (39.4%). However, one patient was diagnosed with peritonitis, and one patient did not show any improvement within three days. During the surgical intervention for the 33 patients who failed conservative management, fibrous bands were identified in 51.5% of patients, while diffuse adhesions were observed in 45.4% of patients. On the other hand, 3.1% of patients showed gangrenous bowels. Out of patients undergoing surgical intervention, two patients (6%) experienced venous thromboembolism, three patients (9%) developed wound infections, two patients (6%) developed fistulas, one patient (3%) experienced a pulmonary complication, and one patient (3%) died.
 Conclusion: Conservative management of Yemeni patients with ASBO is safe and preferred over surgical intervention. This approach can be attempted for 72 hours unless signs or symptoms of bowel compromise or peritonitis develop. By opting for conservative management, the risk of surgical intervention can be reduced, and the length of hospital stay can be shortened. Therefore, conservative management should be considered the primary treatment option for ASBO. However, it is crucial to carefully evaluate and monitor patients to exclude any signs of bowel compromise or peritonitis that would require discontinuation of conservative management and prompt initiation of surgical intervention.

Determination of the Value of Color Doppler Ultrasound in Patients With a Clinical Suspicion of Giant Cell Arteritis.

It is urgent to diagnose giant cell arteritis (GCA) as quickly as possible to prevent irreversible blindness. The traditional gold standard for diagnosing GCA is temporal artery biopsy (TAB). However, TAB lacks diagnostic performance and carries out risks of surgical intervention. The noninvasive color Doppler ultrasound (CDU) seems to be a promising alternative. This study is designed to assess the diagnostic value of CDU in daily clinical practice. In this prospective cohort study, patients with a clinical suspicion of active GCA were included and underwent a CDU of the temporal arteries. If deemed necessary by the referrer, a TAB and/or 18F-fluorodeoxyglucose positron emission tomography with computed tomography was performed. The retrospective clinical diagnosis was determined 1 year after inclusion by two physicians experienced in the field of vasculitis. 242 patients were included and GCA was diagnosed in 73 (30%) patients by the defined retrospective clinical diagnosis. Compared with the retrospective diagnosis, CDU has a sensitivity of 60% (48-72), specificity of 94% (89-97), positive predictive value (PPV) of 81% (70-89), negative predictive value (NPV) of 85% (80-88), and an accuracy of 84% (78-88). A total of 84 (35%) patients underwent TAB. TAB has a sensitivity of 66% (51-79), specificity of 100% (90-100), PPV of 100% (100), NPV of 67% (58-75), and an accuracy of 80% (70-88). This study shows comparable diagnostic performance for CDU and TAB and even better CDU results with a bilateral halo present. Considering the advantages of the noninvasive CDU, it is the diagnostic tool of choice.

Acromioclavicular joint injuries: a review of pathoanatomy, assessment and current management approaches

Acromioclavicular joint (ACJ) injuries represent approximately 10% of all shoulder girdle injuries and their assessment and management can be clinically challenging. This may be for several reasons, including a lack of consensus concerning the reliability of the classification systems, contributing to suboptimal clinical outcomes. A paucity of literature regarding predictive factors for ACJ pathology may also be a factor. Controversy regarding conservative versus surgical management to provide optimal care also continues to be a factor in this clinical challenge, as similar results have been shown with both approaches. There is consensus that low-grade injuries can be treated with non-operative management, but some will go on to have long-term complications. However, the risks of surgical intervention may not out-weigh the benefits. In higher grade injuries there is further controversy over conservative versus surgical management. Improved classification systems and shared decision-making to individualize treatment plans are likely to improve patient outcomes. This review provides an overview of current assessment and management of ACJ injuries in adults.

Risk of Surgical Intervention in Children with Diagnoses of Cancer and Preoperative Malnutrition: A National Analysis

Perioperative nutrition is a critical component of appropriate healing and recovery after surgery. We sought to identify perioperative risk in children with cancer and low preoperative hypoalbuminemia undergoing surgical intervention. We queried the 2015-2019 NSQIP-Peds datasets for children with a primary diagnosis of renal or hepatic malignancy undergoing surgical resection. Postoperative outcomes were evaluated for comparative risk between patients with low albumin (albumin<3.0g/dL) and normal albumin within 30 days of their surgical procedure. Univariate analysis and multivariable logistic regression were conducted to identify perioperative risk in patients with hypoalbuminemia. We identified 360 children with primary diagnosis of hepatic malignancy and 896 children with renal malignancy undergoing surgical resection. Of these, 77 children had hypoalbuminemia. Patients with renal or hepatic malignancy diagnosis and low albumin levels were more likely to experience postoperative dehiscence, need for TPN at discharge, postoperative bleeding or transfusion, unplanned reoperation, and unplanned readmission, based on univariate analysis (all P>0.05). Postoperative bleeding, need for nutritional support at discharge, and unplanned readmission were each associated with hypoalbuminemia. We demonstrate that low preoperative albumin is associated with significant perioperative risk. More attention should focus on perioperative nutritional status of children with cancer who are undergoing major resections.

Small intestine prolapse after vaginal hysterectomy with vaginal dome rupture. A clinical case

The relevance of surgical treatment of pelvic organ prolapse is beyond doubt, due to the high prevalence and risk of surgical intervention during life. Surgical treatment of prolapse today remains the only effective method, however, despite more than 400 methods of surgical correction, the number of complications and relapses does not tend to decrease.&#x0D; This article presents a clinical case of ineffective choice of surgical treatment of genital prolapse with own tissues and vaginal hysterectomy, which subsequently led to the development of enterocele. In the future, the lack of postoperative follow-up and the preservation of a lifestyle that included the performance of hard physical labor led to a rupture of the dome of the vagina and prolapse of the loops of the small intestine.&#x0D; Today, for the prevention of complications and recurrence of genital prolapse, it is mandatory for patients to go through a careful selection for surgical treatment, which should include a clinical study and study of risk factors. When choosing an operative approach, complex treatment is necessary, including the use of the patients own tissues and modern materials that allow creating a reliable physiological framework to strengthen the pelvic organs. When performing this surgery, it is necessary not only to replace the damaged defective pelvic fascia with a new one, but also to create a neofascia that ensures the preservation of the normal function of the pelvic organs.

SURGICAL TREATMENT OF COMPLEX META-DIAPHYSEAL TIBIAL FRACTURES – CURRENT STATE OF THE ART AND NEW TREATMENT MODALITIES

Fractures of a meta-diaphyseal region of the tibia are still challenging in terms of safe, fast, minimal invasive, low - risk surgical treatment. The unstable meta diaphyseal tibial fractures affect proximal and distal one-third of the tibia and result from high-energy trauma, usually combined with severe soft tissue injury. Treatment strategies include mostly operative approaches with various contemporary surgical instrumentations and modern techniques for definitive fracture repair, achieving primary or secondary bone union and better quality of life for patients. In the last decade, new techniques for definitive external plate fixation have been introduced as a part of contemporary trauma armamentarium with good and excellent outcomes.

Alternatives and reduced need for sentinel lymph node biopsy (SLNB) staging for melanoma

Sentinel lymph node biopsy (SLNB) has been introduced in the 1990s to identify patients who might benefit from completion lymph node dissection. Neither SLNB nor CLND improved survival, but SLNB staging did provide the best staging, above Breslow thickness and ulceration. The SLN status and SLN tumour burden were used in all trials until date looking at modern adjuvant systemic therapy with immune checkpoint inhibition (ICI) or targeted therapies (TT). Adjuvant ICI and TT are shifting towards stage II melanoma. The question is whether there is still role for SLNB in melanoma, in this day and age, and if so, how does the future look for SLNB staging? The SLN status and SLN tumour burden might be useful for a consultation to discuss the number needed to treat in a risk/benefit discussion. For stage IIB/C patients, it seems likely, however, that patients will forego a nuclear scan followed by the risk of surgical intervention and morbidity associated with SLNB if they opt to receive adjuvant therapy regardless of the SLNB result. For stage I/IIA, it is still required to detect high-risk patients who might benefit from adjuvant therapy. However, biomarkers are emerging, such as gene expression profilers (GEP), immunohistological signatures and liquid biopsies with ctDNA. There still is a role for SLNB staging in melanoma today, but we expect that the availability of therapeutic option independent of SLNB status as well as emergence of validated biomarkers to predict risk will reduce the need for SLNB staging in the upcoming decade to the point it will no longer be used.

Left ventricular outflow tract pseudoaneurysms and severe paravalvular aortic regurgitation treated by percutaneous approach in a Marfan syndrome patient

A 66-year-old male with a history of Marfan syndrome and resolved infective endocarditis was found to have shortness of breath after a previous aortic valve replacement in 2010. Several severe paravalvular leaks were seen on imaging, and left ventricular outflow tract pseudoaneurysms were identified as the cause of his symptoms which warranted treatment. Due to this patient’s risk of surgical intervention, a retrograde transaortic approach was used.

Risk for Surgical Intervention After Endovascular Aneurysm Repair with Endologix AFX or AFX2 Endovascular Abdominal Aortic Aneurysm Systems Compared with Other High-Volume Abdominal Aortic Aneurysm Devices: A Matched Cohort Study

Risk for Surgical Intervention After Endovascular Aneurysm Repair with Endologix AFX or AFX2 Endovascular Abdominal Aortic Aneurysm Systems Compared with Other High-Volume Abdominal Aortic Aneurysm Devices: A Matched Cohort Study

EP-642 Case Report: Using the Novel Flamingo Device for Endoscopic Treatment of Buried Bumper Syndrome in high risk patients

Abstract Aim Buried Bumper Syndrome is a rare, major late complication of percutaneous endoscopic gastrostomy (PEG) occurring in 1% of cases. It occurs when the internal bumper of the PEG tube erodes into the gastric wall. This lead to a loss of patency, leakage and inability to change the tube endoscopically. Until recently, the treatment was surgical removal under general anaesthesia. However, patients with BBS are likely to have significant co-morbidities thus deeming the procedure high risk. Method We present a case report demonstrating successful treatment of BBS completed endoscopically using the Flamingo device with a good patient outcome. The Flamingo device is a new endoscopic tool that acts like a sphincterotome. Appropriate consent was taken from the patient. This was performed on a 56 year old patient suffering from multiple sclerosis causing dysphagia for which a PEG tube was inserted in 2018 for nutrition. Over time, his care home noticed significant leakage from the site. At gastroscopy, he was diagnosed with BBS. Due to his risk for surgical intervention, the Flamingo device was trialled to remove the buried bumper and allow insertion of a new PEG. Results As demonstrated in the photos, the mucosa was successfully cut allowing the buried bumper PEG to be retrieved. A new PEG was inserted without complication. The patient was discharged the following day and no complications have arisen 3 months later. Conclusion The Flamingo device has proven to be a safe and minimally-invasive method to treat BBS endoscopically in this patient.

Clinical case of coronary artery aneurysm

An aneurysm of a coronary artery is considered to be its expansion by 1.5 times or more over a short distance. The relevance of this pathology is determined by the severity of complications, mainly thrombotic. According to autopsies, it is detected in approximately 1.5% of all autopsies. In the majority of cases, coronary artery aneurysms are asymptomatic, but they also can cause symptoms similar to acute coronary syndrome. A rupture of the aneurysm is a rare but potentially dangerous complication of coronary artery aneurysm. The tactics of managing patients is determined by the severity of symptoms, aneurysm localization, the dynamics of the aneurysm, the presence of myocardial infarction in the area of the altered artery blood supply, the risk of surgical intervention, the distribution and degree of atherosclerotic changes in the coronary vessels, and the possibilities of drug therapy. Reliable diagnostic methods are coronary angiography and multidetector computed tomography. The paper describes a clinical case with patient G., aged 50, who was admitted to the emergency cardiology department with a typical picture of acute coronary syndrome, with stable hemodynamics and without echocardiographic signs of ischemia or infarction. An in-depth study of the coronary system was carried out in order to determine the prospects and the need for planned percutaneous coronary intervention. Computed tomography was performed for this purpose and revealed not only high degrees of stenosis in several coronary arteries, but also structural changes in the coronary system in the form of an aneurysm of the proximal segment of the anterior interventricular branch. The results obtained with computed tomography determined the need for coronary angiography. Its data made it possible to clarify the number, location and severity of stenotic changes in the coronary arteries, as well as to determine other localizations of aneurysms of the coronary system. The summary data of the two studies made it possible to establish that the patient had both stenosing atherosclerosis of the coronary arteries and multiple aneurysms of some arteries at the same time. It was deemed appropriate to continue conservative treatment aimed at preventing recurrence of acute coronary syndrome and thrombosis of coronary artery aneurysm, treatment of hypertension and secondary prevention of atherosclerosis. This clinical case demonstrates that the combined pathology of the coronary arteries can have clinical manifestations in the form of a single episode of acute coronary syndrome.

BIOMECHANICAL AND PHYSIOLOGICAL PRINCIPLES APPLIED IN CHEST WALL RECONSTRUCTION ASSOCIATED WITH RIB FRACTURES

TYPE: Abstract TOPIC: Cardiothoracic Surgery PURPOSE: The aim of this study was to describe osseointegration of osteosynthesis material and risk of surgical intervention when biomechanical and physiological principles are applied in chest wall reconstruction (CWR). METHODS: All adult patients with pulmonary contusion, multiple rib fractures, flail chest, hemothorax or pneumothorax associated with rib fractures who underwent CWR between March 2012 and December 2016 in emergency department retrospectively included.Titanium clips pressure-fitted at 2 cm proximal and distal were used at each fracture site. Curvature of the clip was made to simulate the natural curvature of the costal arch. In all cases the vascular and nervous package was released. Postoperative follow-ups were obtained from medical records and the integration of the osteosynthesis material was assessed. RESULTS: The 60 patients were 37 men and 23 woman, average age of 44 years. Hospital stays between 7 and 16 days. At 30 days postoperative complications had been recorded such as respiratory insufficiency (n=2) and acute myocardial infarction (n=1).Osteointegration of the osteosynthesis material was found in 59 patients (98.3%) and 1 patient (1.6%) present refracture and mobilization of a titanium implant, for which it was surgery reintervened and the defect corrected CONCLUSIONS: In our study, we found a very high percentage of osseointegration when using the biomechanical principles in the techniques for CWR. CLINICAL IMPLICATIONS: The healing process near fracture sites relies in a correct immobilization,adequate vascularization and formation of bone callus and new bone therefore, by using titanium clips combined with different biomechanical principles they help this purpose by improving the conditions at the fracture site. DISCLOSURE: Nothing to declare. KEYWORD: CHEST WALL RECONSTRUCTION

Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections

To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections. We conducted a multicenter cohort study of children 2months to 18years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors. Of 1579 patients entered, median age was 5.4years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated witholder age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/μL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%). In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.

Single-centre survey of women reflecting on recent experiences and preferences of oral intake during labour.

Consensus-based recommendations guiding oral intake during labour are lacking. We surveyed women at a tertiary women's hospital about preferences for and experiences of oral intake during labour, gastrointestinal symptoms during labour and recalled advice about oral intake. Women who experienced labour completed a postpartum survey with responses as free text, yes-no questions and five-point Likert scales. We identified demographic data and risk factors for surgical or anaesthetic intervention at delivery from medical records. We summarised free text comments using conventional content analysis. One hundred and forty-nine women completed the survey (47% response rate). Their mean (SD) age was 31 (four) years, birthing at median gestation of 39weeks (interquartile range: 38-40). One hundred and twenty-two (83%) and 44 (30%) women strongly agreed or agreed they felt like drinking and eating respectively during labour. Ninety women (61%) reported nausea and 47 women (32%) reported vomiting in labour. Forty-one women (28%) did not receive advice on oral intake during labour. Maternal risk factors for surgical intervention were identified in 72 (48%) women and fetal risk factors in 27 (18%) women. Thirty-one women (21%) delivered by emergency caesarean section. Pregnant women received variable advice regarding oral intake during labour, from variable sources. Most women felt like drinking but not eating during labour. Guidelines on oral intake in labour may be beneficial to women, balancing the preferences of women with risks of surgical intervention.

Transfemoral aortic valve replacement in a nonagenarian with aortic stenosis and cardiac amyloidosis: case report

BackgroundCardiac amyloidosis (CA) is diagnosed with increasing frequency in the elderly population with severe aortic stenosis (AS), especially with the low-flow, low- gradient phenotype. Prognosis is poor with no treatment.Case presentationThe patient is a 94-year-old active male who presented with a stroke that fully resolved. He was found to have low-flow, low-gradient severe AS, along with concomitant CA. Gradients across the aortic valve worsened with the dobutamine challenge test. He underwent successful transfemoral aortic valve replacement (TAVR) and did well postoperatively, where he remained in the hospital for only one day. Treatment of his CA with Tafamidis was recommended; however, the patient declined due to its cost and personal preference.ConclusionTo our knowledge, we report on one of the oldest patients to undergo TAVR for low-flow, low-gradient AS with concurrent CA (AS-CA). It might be prudent to screen elderly patients with AS for CA, as prognosis is worse with medical management alone. TAVR has overall improved survival in patients with AS-CA and is considered the procedure of choice, as these patients are typically older and at higher risk for surgical intervention.