Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

Bacterial pattern in adult decompensated liver cirrhosis ascitic fluid infection during first 5 months of second wave Covid-19 pandemic at tertiary hospitals in Jakarta Indonesia

Objectives: To find out bacterial pattern of ascitic bacterial infection in adult decompensated liver cirrhosis during Covid-19 pandemic at three tertiary referral hopsitals in Jakarta. Materials and Methods: 18 years old or more decompensated liver cirrhosis patient due to any cause with grade 2 or more ascites admitted consecutively to emergency room, inpatient and outpatient unit in Jakarta's three tertiary referral hospitals: Cipto Mangunkusumo National General Hospital, Gatot Soebroto Central Army Hospital, Fatmawati General Hospital would be performed paracentesis ascitic tap during January to May 2021. Bedsite aerobic and anaerobic bacterial blood culture bottles of 10 mL inoculation ( aerobic BACT/ALERT® FA Plus and anaerobic BACT/ALERT® FN Plus bioMerieux Incorporation) were acquired under aseptic and antiseptic standards before antibiotic administration or at least 4 h after it. Diphtheroids species, Bacillus species and Staphylococcus epidermidis were considered contaminant. Results: There were 98 ascitic culture specimens from 98 grade 2 and more ascites decompensated liver cirrhosis patients. Basic characterisitic data included: 32.6% female, 67.4% male, history of hospitalization and antibiotic admission in the last previous 3 months 76.5%, due to viral hepatitis B 38.5%. Bacterial growth was found in 11 specimens ( 11.1%) including 6 aerobic gram negative ( 54.5%): Aeromonas hydrophila, Enterobater aerogenes, Klebsiella pneumonia ( 2 specimens), Acinetobacter species, Pseudomonas aeruginosa and 5 aerobic gram positive ( 45.4%): Enterococcus faecalis, Staphylococcus cohnii ssp cohnii, Staphylococcus cohnii ssp urealyticus, Staphylococcus haemolyticus, Micrococcus luteus. There were no positive culture for Escherichia coli and anaerobic bacteria. Conclusion: During second wave of Covid-19 pandemic in Jakarta, there were almost equal proportion of gram positive and negative bacterial in adult decompensated liver cirrhosis ascitic fluid bacterial infection patients in tertiary hospitals. This result reminds clinicians of bacterial pattern shift in ascitic fluid infection in decompensated liver cirrhosis during pandemic.

THE IMPACT OF THE CORONAVIRUS PANDEMIC AND GOVERNMENT LOCKDOWNS ON LIVER DISEASE HOSPITALIZATIONS, INPATIENT MORTALITY, AND LIVER TRANSPLANT SURGERY IN CALIFORNIA: A POPULATION-LEVEL ANALYSIS

Introduction: The COVID-19 pandemic created massive disruptions in established healthcare utilization patterns. The impact of these interruptions in patients with liver diseases including cirrhosis is underreported at a population level. As such, we used a large, state-wide dataset to report inpatient liver disease outcomes during the 2020 Coronavirus pandemic using 2018 and 2019 as comparator years. Methods: Using the all-payer California State Inpatient Dataset for 2018-2020, we explored year-to-year trends, and 2020 month-to-month variations in liver-related (alcoholic liver disease, hepatocellular cancer, cirrhosis and attendant complications including hepatic encephalopathy, variceal bleeding, ascites, spontaneous bacterial peritonitis [SBP], and hepatorenal syndrome) hospitalizations, length of stay, and inpatient mortality (all-cause & viral pneumonia-specific) using joinpoin, linear, and logistic regression models. We also investigated trends in endoscopy utilization for esophageal variceal bleeding and variations in liver transplantation during the pandemic. Results: There was an increase in decompensated cirrhosis hospitalizations (264,008 in 2019 to 272,092 in 2020, p<0.001) and all-cause mortality (11.6% in 2019 to 13.8% in 2020, p<0.001). Alcoholic hepatitis and alcohol-related liver disease hospitalizations also increased in this period (ptrend<0.001) [Fig 1]. The 2020 month-to-month trend analyses showed the lowest hospitalization rates in April, coinciding with the early stages of the pandemic. This was associated with significant trend in mortality for patients with cirrhosis (ptrend<0.001) and alcoholic liver disease (ptrend=0.004) where mortality was highest in December 2020. Viral pneumonia admissions increased from 0.3% (n=940) in 2019 to 6% (n=18,544) of all hospitalizations (p<0.001) and this was associated with a significant increase in respiratory failure and death, 0% in 2019 to 1.8% in 2020 (p<0.001). Sensitivity analysis showed that decompensated cirrhosis accounted for >95% of viral pneumonia deaths in 2020 among all liver disease patients. There was no significant change in rates of liver transplant surgery during the 2020 pandemic (ptrend=0.36). In addition, endoscopic treatment for esophageal variceal bleeding within the first 24 hours of admission was not significantly different between 2019 and 2020 (44% vs 41%, p=0.65), and rates of paracentesis for SBP were also comparable (30% in 2019 vs 30.6% in 2020, p=0.07). Conclusions: The Covid-19 pandemic resulted in significant increases in hospitalization for decompensated cirrhosis and alcohol-related liver disease in California. Patients with decompensated cirrhosis accounted for the majority of viral pneumonia cases and deaths among all liver-related admissions. However, liver transplantation and endoscopy utilization rates were comparable with prepandemic numbers. (Figure Presented) Figure 1: Trends in hospitalization, length of stay, and mortality rates of liver diseases in California from 2018 to 2020(Figure Presented) Figure 2: 2020 month-to-month trends in liver-related hospitalizations and mortality in California State

BILATERAL PLEURAL EFFUSIONS WITHOUT SIGNIFICANT ASCITES IN AN OVARIAN HYPERSTIMULATION PATIENT RECOVERED FROM COVID-19: A CASE REPORT

OBJECTIVE: To describe a patient who developed severe ovarian hyperstimulation syndrome (OHSS) with uncharacteristic features after recent COVID-19 infection. MATERIALS AND METHODS: A patient with prior mild COVID-19 developed an atypical case of OHSS with significant bilateral pleural effusions requiring bilateral thoracentesis and only minimal abdominal ascites. Isolated pleural effusions without significant ascites in not frequently found in patients with OHSS, with only one case with an effusion requiring a thoracentesis in 771 patients in a 1995 Canadian study. COVID-19 is known to cause inflammatory responses in the lung, however, pleural effusions are a rare symptom and usually only in those with severe disease. Long-standing damage from COVID-19, or ''post-COVID conditions'' is still under active investigation but can occur in patients even with mild disease. RESULTS: A 25yo G0 (BMI 27, AMH 9) without significant past medical or surgical history underwent IVF due to male factor infertility and polycystic ovarian syndrome (PCOS). She was diagnosed with COVID-19 5 weeks prior to stimulation and reported a mild course not requiring hospitalization. She underwent a long agonist protocol with a peak E2 of 6700 on day of HCG trigger (5000u) and had 42 oocytes retrieved. On POD #3, she presented with abdominal pain with distension and shortness of breath. A therapeutic paracentesis was performed with 500 ml drained and minimal improvement of symptoms. Due to significant response, she had a freeze all embryo cycle. On POD #5, she had worsening shortness of breath and underwent a CT pulmonary embolism (PE) protocol which did not demonstrate a PE but did show significant bilateral pleural effusions without abdominal ascites. She then underwent a bilateral thoracentesis with 800 ml drained from left lung and 1000 ml drained from right lung. She had significant improvement and returned to baseline after two days. CONCLUSIONS: OHSS is an uncommon side effect of gonadotropin stimulation, but this patient had multiple risk factors including age, PCOS diagnosis, AMH level, peak E2 level and number of oocytes retrieved. Ascites typically appears before pleural effusions. We postulate that the recent COVID-19 infection may have increased fluid accumulation preferentially to the lungs rather than the abdomen. IMPACT STATEMENT: With the ever increasing knowledge of post- COVID conditions, one must consider its potential long-term sequalae. Unexpected or atypical presentations may be due to COVID-19. The physiologic changes that occur with fertility treatment may be exacerbated by recent, even mild, COVID-19 illness.

POS-153 COLLAPSING GLOMERULOPATHY IN A FILIPINO FEMALE PRESENTING WITH NEPHROTIC SYNDROME POST-PARTUM

Introduction: Collapsing Glomerulopathy (CG) is a rare entity presenting as nephrotic syndrome and rapidly progressive renal deterioration. It has been first identified among African-American patients with nephrotic syndrome. Subsequently, it has been called HIV-associated nephropathy (HIVAN) after a number of patients with HIV were found to have CG. It has re-emerged recently among patients with COVID-19 dubbing it as the new HIVAN. In the Philippines, Focal Segmental Glomerulosclerosis (FSGS) is the second most common glomerular disease but with no available data on the subtypes.To our knowledge, this is the first case of collapsing glomerulopathy in the country to be published. Methods: This is a case report of primary Collapsing Glomerulopathy seen in our institution. Results: The case is a 36 year-old Filipino female admitted due to edema which started 2 weeks post-partum. She is gravida 3 para 3 (1203), with no complications in all the pregnancies. She had no known comorbidities. Social history was negative for intravenous or illicit drug use. She initially sought consult with her obstetrician where work up showed hypoalbuminemia and diffuse hepatic disease on ultrasound. She was referred to a gastroenterologist where albumin infusion and paracentesis was done but with no improvement. She developed anasarca and was admitted in our institution. Paracentesis was attempted but only minimal ascitic fluid was obtained. Serum ascites albumin gradient was low and baseline laboratories showed high creatinine at 146 mmol/L, hypoalbuminemia at 16 g/L and +3 albumin on urinalysis. Further testing showed a 24-hour urine protein of 11 grams. ANA and anti-DsDNA were negative and c3 and c4 levels were normal. Hepatitis profile was negative for infection. Abdominal CT scan revealed a hypoenhancing pancreatic tail lesion, breast cyst and nodule. Tumor markers showed high CA-125, CA 19-9 and CA 15-3. Breast ultrasound showed simple breast cyst. Gyneocology consult was called where pap smear done was negative for malignancy. Surgery service recommended observation and monitoring for the pancreatic and breast lesions. Kidney biopsy was delayed due to new onset bacterial pneumonia. COVID-19 RT-PCR test was negative. Kidney biopsy was done after lysis of fever. Pending pathologic diagnosis, patient was discharged clinically improved with no edema. She was sent home on prednisone, ARB, statin, fenofibrate and anti-platelet. On follow up at the outpatient clinic, the kidney biopsy result came out to be collapsing glomerulopathy, acute tubular injury, mild interstitial fibrosis and atrophy. HIV test was done and came out negative. Bipedal edema has recurred and albumin/creatinine ration was 731mg/g. She was then started on tacrolimus. She has been on regular follow up and currently has no edema and has ACR of 79mg/g and normal creatinine level. Conclusions: This is an interesting case as the primary glomerular disease has been masked by the initial laboratory findings. The ultrasound showed parenchymal liver disease. Further work-up revealed multiple lesions in the pancreas, breasts and lymph nodes with high tumor-markers which led us to think of paraneoplastic nephrotic syndrome. The renal biopsy revealed a rare diagnosis with no previous local data. This serves as an index case for primary collapsing glomerulopathy in a Filipino patient on remission after being treated with tacrolimus. No conflict of interest

In office management of optic capture of scleral fixated posterior chamber intraocular lenses.

INTRODUCTION: Optic capture of sutured scleral fixated posterior chamber intraocular lenses (PC IOLs) is an occasional complication resulting in blurred vision and discomfort. METHODS: A retrospective study of the management of 18 eyes (3.6%) with optic capture out of 495 eyes with scleral fixated IOLs during the study period. 54 procedures were performed in the management of optic capture of sutured scleral fixated PC IOLs. An in-office technique was utilized to relieve the optic capture by repositioning the optic posterior to the iris. This technique was performed after topical anesthesia and topical 5% betadine with the patient stably positioned at the slit lamp. Using a 30-gauge needle, sometimes after a 15-degree paracentesis blade, the needle was advanced in a parallel plane above the iris until the tip reached the edge of the captured optic. The optic is engaged in the inferior periphery away from the central visual axis, and pushed gently posteriorly just enough to reposition the optic posterior to the iris. In some cases, pilocarpine 2% drops were utilized after the procedure to decrease the risk of recapture of the optic. RESULTS: All 54 procedures were successfully performed in the office without significant pain or discomfort. Vision before optic capture, during optic capture, and at the first office visit after optic capture were comparable. There were not any cases of endophthalmitis, hyphema, iris trauma, iris prolapse or keratitis. While eight patients only had one episode of optic capture, 10 patients had multiple episodes of optic capture, all managed with this in office procedure. Recurrent optic capture occurred more frequently in eyes with fixation at less than 2 mm from the limbus than eyes with scleral fixation at 2 mm from the limbus. CONCLUSION: Reposition of the optic after pupillary capture of a scleral fixated PC IOL can be successfully performed in the office without discomfort or significant complications and is an alternative management option to a return to the operating room. This procedure may be especially important when there is poor access to the operating room or restricted access to the operating room as during the COVID19 pandemic.