The Three Most Discussed Questions in Carotid Artery Surgery. Review of Russian and Foreign Studies in the Last Five Years

This literature review analyzes Russian and foreign publications over the past five years on the three most discussed issues related to carotid artery surgery: l.Which is more effective: eversion carotid endarterectomy or conventional carotid endarterectomy with patch closure? 2. Which is better: carotid endarterectomy (CEE) or carotid angioplasty and stenting (CAS)? 3. How soon after the development of ischemic stroke should cerebral revascularization be performed? The authors of the article came to the following conclusions: 1. According to the majority of large studies and meta-analyses, conventional CEE with patch closure is associated with a higher risk of internal carotid artery restenosis compared to eversion carotid endarterectomy. Single-center trials with small samples of patients do not find statistical differences between the outcomes of applying both surgical techniques. 2. Large multicenter randomized trials are required to address the effectiveness of CEA and CAS in symptomatic and asymptomatic patients. To date, there has been no consensus on this matter. 3. CEE and CAS can be equally effective and safe in the most acute and acute periods of ischemic stroke when performed in the presence of a mild neurological deficit and the ischemic brain lesion not exceeding 2.5 cm in diameter. Nevertheless, the choice of treatment strategy should be made strictly personalized by a multidisciplinary council based on the experience of the institution and current recommendations. © 2023 Sklifosovsky Research Institute for Emergency Medicine. All rights reserved.

Changes in Kawasaki disease incidence and phenotype during the COVID-19 pandemic

INTRODUCTION. The aetiology of Kawasaki disease (KD) remains unknown. Changes in infectious exposure during the COVID-19 pandemic owing to infection prevention measures may have affected the incidence of KD, supporting the pathogenic role of an infectious trigger. The purpose of this study was to evaluate the incidence, phenotype and outcome of KD before and during the COVID-19 pandemic in Denmark. METHODS. This was a retrospective cohort study based on patients diagnosed with KD at a Danish paediatric tertiary referral centre from 1 January 2008 to 1 September 2021. RESULTS. A total of 74 patients met the KD criteria of whom ten were observed during the COVID-19 pandemic in Denmark. Alof these patients were negative for SARS-CoV-2 DNA and antibodies. A high KD incidence was observed during the first six months of the pandemic, but no patients were diagnosed during the following 12 months. Clinical KD criteria were equally met in both groups. The fraction of intravenous immunoglobulin (IVIG) non-responders was higher in the pandemic group (60%) than in the in the pre-pandemic group (28.3%), although the rate of timely administered IVIG treatment was the same in both groups (>= 80%). Coronary artery dilation was observed in 21.9% in the pre-pandemic group compared with 0% in KD patients diagnosed during the pandemic. CONCLUSION. Changes in KD incidence and phenotype were seen during the COVID-19 pandemic. Patients diagnosed with KD during the pandemic had complete KD, higher liver transaminases and significant IVIG resistance but no coronary artery involvement.Copyright © 2023, Almindelige Danske Laegeforening. All rights reserved.

Unique vascular complication following extended VV-ECMO support

Objectives: To present an unusual complication related to prolonged ECMO support in a patient with COVID19 induced acute respiratory syndrome (ARDS). Method(s): Clinical chart review of the care process after obtaining the informed consent from the patient. Result(s): A 48-year-old female with COVID-19 infection during second wave of pandemic in August 2021 progressed to severe ARDS. She was put on VV-ECMO support after failing conventional therapy for refractory hypoxemia. Her cannulation configuration included a 25 F venous drainage cannula in the right femoral vein and a 21 F venous return cannula in the right Internal Jugular (IJ) vein. Cannulations were performed using the ;Seldinger technique;under USG guidance, and no difficulties or complications were reported. Her hospital course was notable for delirium, and intermittent bleeding from the cannula sites. After 80 days of support, she showed adequate respiratory improvement which allowed ECMO decannulation. She continued to show improvement, and was eventually discharged after 102 days of total hospital stay. During her 6 weeks follow-up clinic visit a palpable thrill was noted at the jugular ECMO cannula site. A CT angiogram of the neck demonstrated a large venous varix connecting the right IJ and the left common carotid artery with filling from the left common carotid artery. ECMO cannulation site complications such as aneurysm, clots, infections and stenosis are well known. What was unusual in this case is the nature of the aneurysm given that there were no arterial procedures performed on the left side of the neck. She was managed by an ;Amplatzer plug;to the carotid artery at the level of the connection to the varix without any complications. Conclusion(s): Longer duration of ECMO support needs careful follow-up for timely recognition and management of vascular complications. (Figure Presented).

Vascular Surgery 2023

We are rapidly approaching the 2-year anniversary since Vascular Surgery became a distinct speciality in surgery. Dr Chan addressed the importance of the subspeciality Vascular Nurse as an essential partner in modern vascular service. Dr Pang reviewed his 3-year results of advanced endovascular interventions for high-grade Trans-Atlantic Inter-Society Consensus-Class D (TASC-D) femoropopliteal inventions, and compared patency and clinical outcomes with the traditional bypass operations. [Extracted from the article] Copyright of Surgical Practice is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Pipeline Embolization Device for intracranial aneurysms presenting with mass effect: a large Chinese cohort.

BACKGROUND: Unruptured intracranial aneurysm treatment aims to reduce the risk of aneurysm rupture and bleeding, relieves symptoms and improve the quality of life for patients. This study aimed to assess the safety and efficacy of Pipeline Embolization Device (PED, Covidien/Medtronic, Irvine, CA) treatment for intracranial aneurysms presenting with mass effect in real-world settings. METHODS: We selected patients from the PED in China Post-Market Multi-Center Registry Study with mass effect presentation. The study endpoints included postoperative mass effect deterioration and mass effect relief at follow-up (3-36 months). We conducted multivariate analysis to identify factors associated with mass effect relief. Subgroup analyses by aneurysm location, size and form were also performed. RESULTS: This study included 218 patients with a mean age of 54.3±11.8 years and a female predominance of 74.0% (162/218). The postoperative mass effect deterioration rate was 9.6% (21/218). During a median follow-up period of 8.4 months, the mass effect relief rate was 71.6% (156/218). Notably, immediate aneurysm occlusion following treatment was significantly associated with mass effect relief (OR 0.392, 95% CI, 0.170 to 0.907, p=0.029). Subgroup analysis demonstrated that adjunctive coiling contributed to mass effect relief in cavernous aneurysms, while dense embolism impeded symptom relief in aneurysms<10 mm and saccular aneurysms. CONCLUSIONS: Our data confirmed the efficacy of PED in relieving mass effect. The findings of this study provide support for endovascular treatment to alleviate mass effect in unruptured intracranial aneurysms. TRIAL REGISTRATION NUMBER: NCT03831672.

Cardiac Involvement in Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) in Poland.

Multisystem inflammatory syndrome in children (MIS-C) is an immune-mediated complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Cardiovascular system is commonly involved. Acute heart failure (AHF) is the most severe complication of MIS-C, leading to cardiogenic shock. The aim of the study was to characterise the course of MIS-C with a focus on cardiovascular involvement, based on echocardiographic (echo) evaluation, in 498 children (median age 8.3 years, 63% boys) hospitalised in 50 cities in Poland. Among them, 456 (91.5%) had cardiovascular system involvement: 190 (48.2%) of patients had (most commonly atrioventricular) valvular insufficiency, 155 (41.0%) had contractility abnormalities and 132 (35.6%) had decreased left ventricular ejection fraction (LVEF < 55%). Most of these abnormalities improved within a few days. Analysis of the results obtained from two echo descriptions (a median of 5 days apart) revealed a >10% increase in LVEF even in children with primarily normal LVEF. Lower levels of lymphocytes, platelets and sodium and higher levels of inflammatory markers on admission were significantly more common among older children with contractility dysfunction, while younger children developed coronary artery abnormality (CAA) more often. The incidence of ventricular dysfunction might be underestimated. The majority of children with AHF improved significantly within a few days. CAAs were relatively rare. Children with impaired contractility as well as other cardiac abnormalities differed significantly from children without such conditions. Due to the exploratory nature of this study, these findings should be confirmed in further studies.

Rare Rupture of Small 4.3 cm Abdominal Aortic Aneurysm.

Abdominal aortic aneurysm (AAA) is a common medical condition with the feared, and often fatal, complication of rupture. The risk of rupture has been well documented to correlate with aneurysm size. It is exceedingly rare for an AAA less than 5 cm to rupture. This case report demonstrates an asymptomatic 4.3 cm AAA that ruptured while admitted to the hospital with COVID-19 pneumonia. The patient was successfully managed with an endovascular aortoiliac stent graft. Although rare, in patients with small AAA, rupture must remain in the differential diagnosis in the setting of acute onset abdominal or back pain. Furthermore, when quickly recognized, these patients can be safely managed with an endovascular approach.

Safety and Feasibility of Conversion from Venoarterial to Venovenous Extracorporeal Membrane Oxygenation in Pediatric Patients

Introduction: Children requiring venoarterial (VA) extracorporeal membrane oxygenation for long durations may have increased risk of complications compared to venovenous (VV) ECMO. The purpose of this study was to evaluate the feasibility and safety of conversion from VA to VV ECMO. Method(s): This is a retrospective review of all children requiring VA ECMO who underwent conversion to VV ECMO at a single institution, from 2015- 2022. Indications for and methods of conversion were examined as well as adverse events including re-operation, ischemic complications, renal failure, and mortality. Descriptive statistics were calculated. Result(s): Of 422 pediatric patients on initial VA ECMO, only three children (0.7%) underwent conversion from VA to VV support, ages 10-19: for hypoxic respiratory failure due to COVID19, for cardiac dysfunction following orthotopic heart transplant, and for sepsis with associated left ventricular dysfunction. The indications for conversion were bleeding from cannulation site (n=2, 66%) and an anticipated prolonged ECMO run (n=1, 33%). For all three patients, the method of conversion was cutdown with femoral arterial repair followed by placement of additional jugular venous cannulas (n=2, 66%) or insertion of a singular jugular bicaval venous cannula with removal of the femoral cannulas (n=1, 33%). The median time on VA ECMO prior to conversion was 8 days (range 4-54 days). All 3 patients were managed with renal replacement therapy with 1 patient (33%) progressing to long term dialysis. There were no significant ischemic limb complications although one (33%) patient developed a femoral artery pseudoaneurysm that required re-operation. Two of the three patients (66%) were able to be decannulated at a median of 23.5 days (range 8-39 days) following conversion to VV ECMO and survived to discharge. The other patient was unable to be decannulated after successful conversion and care was withdrawn. Conclusion(s): Based on this small pilot study, conversion to VV ECMO from initial femoral VA ECMO cannulation is safe and feasible. Indications for conversion include coagulopathy and need for extended ECMO run after recovery of cardiac function.

Recurrent Liver Abscess in a Non-Toxic Patient

Introduction: Liver abscesses are caused by direct spread from peritonitis, biliary tract infection or via hematogenous seeding from a distant source. Most are polymicrobial, however Escherichia coli and Klebsiella pneumoniae are the most common offending pathogens. Patients usually present with pain, fever, and clinical signs of infection. We describe a case of spontaneous liver abscess in a non-toxic patient that recurred 10 years after a previous abscess. Case Description/Methods: A 73-year-old-man with a history of type 2 diabetes mellitus, hypertension, CAD status post CABG and PCI 3 years ago, and abdominal aortic aneurysm status post endovascular aneurysm repair presented with 2 weeks of dark urine. After receiving his COVID-19 booster and influenza vaccinations, he developed flu-like symptoms with a self-resolving fever of 101.8degreeF. He had dark amber urine without dysuria or hematuria. Later, he experienced generalized weakness and decreased oral intake. Outpatient labs showed elevated liver function tests, and he was told to present to the ED. On arrival, he was afebrile with stable vitals. Physical exam was unremarkable. Laboratory evaluation showed a hemoglobin of 11.7 g/dL, sodium of 133 mEq/L, creatinine of 1.4 mg/dL, aspartate aminotransferase of 117 U/L, alanine aminotransferase of 212 U/L, alkaline phosphatase of 825 U/L, total bilirubin of 4.1 mg/dL, and direct bilirubin of 2.1 mg/dL. Triple-phase CT showed a 2.8 cm mass in the right liver lobe with linear enhancement. Ultrasound showed mixed echogenicity measuring 3.6 x 2.9 x 3.3 cm in segment 8 of the liver. On further evaluation, patient had an E. coli abscess diagnosed 10 years prior, managed with antibiotics and drainage. At that time, the abscess was within the right inferior liver lobe, similar to his current abscess. LFTs downtrended. Abscess was aspirated, with culture growing oxidase negative, gramnegative rods, likely E. coli. Patient started on ceftriaxone and metronidazole, to undergo colonoscopy as an outpatient and rule out colonic bacterial translocation. Discussion(s): Pyogenic liver abscess can result in significant morbidity and mortality because of worsening infection and sepsis. Abscesses occur because of spread from adjacent infection or after recent surgeries. Recurrence is very rare. Here, we describe a very unusual case of a pyogenic liver abscess growing E. coli in a non-toxic patient, with the same location and causative organism as an abscess managed 10 years prior. (Figure Presented).

Clinical Features, Laboratory Findings Outcomes in Multisystem Inflammatory Syndrome (Mis-C) Following Covid-19 Infection - a Multicenter, Observational, Ambidirectional Cohort Study in Rio De Janeiro State, Brazil

Objectives: As of March 5th, 2022, around 1.585 cases of MIS-C and 98 deaths (6,4%) were reported in Brazil. The state of Rio de Janeiro State (RJ) having 94 cases (5,9%) and 4 deaths (4,2%)1.Our aim was to evaluate clinical and laboratory features, and management of MIS-C in seven pediatric hospitals in RJ, Brazil. Method(s): Multicenter, observational, ambidirectional cohort study in seven tertiary hospitals in RJ(Brazil), assessing medical charts of pediatric inpatients (0-18 years) diagnosed with MIS-C according to WHO/CDC criteria, from August, 2020 to February, 2022. Descriptive statistics were used to analyze distributions of continuous variables, frequencies, and proportions. Result(s): A total of 112 cases of MIS-C were enrolled. The mean age was 4.2 years and thre was male predominance (59,8%). All cases had a SARS-CoV-2 contact (29.5% close contact;31.3%:positive PCR;serology:43.8%).Only 12.5% had comorbidities. Length of stay (LOS) was 7 days.Median duration of fever was 8 days. Most common symptoms were: rash(67%);gastrointestinal (67%);conjunctivitis (42%);neurological(39.6%);cardiovascular(37.5%);cervical lymphadenopathy (36.6%), and shock/hypotension(28.6%).Co-infection occurred in 3 patients. Forty-four patients fulfilled criteria for Kawasaki disease. Most patients were admitted to PICU(12;62,5%) for amedian of 2 days. Respiratory distress was seen in 18,7%;hypotension:28,6%, and shock in 23,2%. Main laboratory findings were: high C-reactive protein in 95%;D-dimer:77%, anemia:77%, thrombocytosis:63%;transaminitis:43.8%, lymphopenia:38%;hypoalbuminemia:34%;thrombocytopenia: 29%;hypertriglyceridemia:28%, and high pro-BNP in 27%. Echocardiogram was performed in 91/112 patients;abnormal in 70,3%;exhibiting myocardial dysfunction( 25%);pericardial effusion(21%);coronary dilation/aneurysms(11%) and, valvulitis (14.5%). IVIG+corticosteroids (CTC) were administered in 59.8%(67/ 112);18.6%(18/112) IVIG only;10.7%(12/112) CTC only;3.4%(4/112)biologics, and 15(13.3%) received no treatment. ASA low dose in 77.7% (87/112) and moderate/high dose in 34.8%. Oxygen support was needed in 27,7%;vasoactive amines:18,7%;dialysis:5,3%, and transfusion:18,7%.One patient died from a cytokine storm syndrome. Conclusion(s): Our study reports a higher number of MIS-C cases in RJ than the number reported to Brazilian authorities, highlighting underreporting. Our patients were younger, had fewer comorbidities, cardiovascular/gastrointestinal/renal involvement, shortest LOS in ICU, and a higher frequency of myopericarditis.

A Diagnostically Challenging Case of Primary Pancreatic Lymphoma

Introduction: Primary Pancreatic Lymphoma (PPL) is the exceedingly rare instance of extranodal Non-Hodgkin's Lymphoma developing mainly in the pancreas.We report a diagnostically challenging case of a patient presenting with a rapidly growing pancreatic mass, found to have PPL. Case Description/Methods: A 48-year-old female with past history of tobacco use presented with several months of cramping abdominal pain following COVID-19 infection. She denied weight loss, fevers, or night sweats. Her physical exam, CBC, CMP, lipase, LDH, and CA 19-9 were unremarkable. An abdominal ultrasound revealed a 2.8 x 1.9 x 3 cm cystic mass of the pancreatic head, most congruent with a pseudocyst. Worsening abdominal pain prompted repeat ultrasound one month later, which showed a doubling in size. Endoscopic ultrasound (EUS) with fine needle aspiration of the cystic mass and surrounding lymph nodes yielded cystic contents and reactive lymphadenopathy. Two months later, her abdominal pain worsened and repeat imaging showed further doubling in size with encasement of the celiac plexus. A second FNA performed via EUS redemonstrated cystic contents. An ultrasound-guided core needle biopsy of the mass revealed necrotic CD301 diffuse large B cell lymphoma (DLBCL). PET scan was suggestive of stage IV PPL (Figure). Imaging also identified an inguinal lymph node that returned as CD101 BCL61 high grade follicular lymphoma, which was thought to be a distinct lesion. She was started on R-CHOP. Her clinical course was complicated by the formation and subsequent rupture of a splenic artery pseudoaneurysm, gastrointestinal bleeding, anuric kidney injury, and intestinal ischemia. She ultimately transitioned to comfort care. Discussion(s): Primary pancreatic lymphoma comprises 0.6% of extranodal lymphomas and 0.2% of primary pancreatic tumors. The clinical presentation is often vague and includes abdominal pain, B symptoms, jaundice, or bowel obstruction. The diagnostic criteria according to the WHO requires that the (1) majority of tumor burden be localized to the pancreas and (2) existing nearby and distant lymph node involvement should be secondary to pancreatic presentation. A biopsy is required to diagnose PPL, which is histologically most often DLBCL. Our case highlights the challenges associated with diagnosing PPL despite two EUS with FNA. Although rare, one should proceed with a high index of suspicion for PPL in any patient presenting with a rapidly enlarging pancreatic mass.

Marginal Artery of Drummond Pseudoaneurysm Masquerading as Fistulous Tract Resulting in Recurrent Lower Gastrointestinal Bleeding

Introduction: The mortality rate of patients hospitalized with a lower gastrointestinal bleed has been reported at 1.1% in the United States from 2005 to 2014. Pseudoaneurysms, typically associated with pancreatitis, have been described in case reports as a rare condition with a small subset presenting as gastrointestinal bleeding. Our study describes a rare case of recurrent lower gastrointestinal bleeding diagnosed as a pseudoaneurysm by endoscopy and angiography. Case Description/Methods: A 38-year-old male presented to our facility from a long-term care facility with hematochezia and blood clots per gastrostomy-jejunostomy. He had recently been hospitalized for severe coronavirus disease 2019 with a complicated hospital course in the intensive care unit including necrotizing pancreatitis with an abdominal drain, multiple secondary infections, tracheostomy, and percutaneous endoscopic gastrostomy-jejunostomy. On previous hospitalization, he was found to have a small pseudoaneurysm of the gastroduodenal artery and received embolization of the gastroduodenal and gastroepiploic arteries at that time. During transport to our hospital, he was noted to have tachycardia, hypotension requiring norepinephrine, and was transfused one unit of red blood cells. Hemoglobin at this time was 7.5 g/dl after transfusion. Esophagogastroduodenoscopy was completed and showed a gastrojejunostomy tube in the expected location but was noted to be tight to the mucosa, which was pale in appearance. Flexible sigmoidoscopy revealed localized areas of edematous and erythematous mucosa with some associated oozing throughout the sigmoid colon. Repeat evaluation was completed one week later due to recurrent hematochezia. Colonoscopy was performed with identification of an apparent fistulous tract in the sigmoid colon located at 35 cm. Computed tomography angiography localized a pseudoaneurysm arising from the marginal artery of Drummond just proximal to its anastomosis with the ascending branch of the left colic artery and was successfully embolized. Discussion(s): Pseudoaneurysms, such as the one described in this case, have been shown to be associated with pancreatitis and can result if a pseudocyst involves adjacent vasculature. Gastrointestinal bleeding is a rare presentation of this condition. However, this case highlights the importance of repeat colonoscopy and angiography in the setting of a lower gastrointestinal bleed of unknown etiology.

Incidental findings arising from targeted lung health checks: a GP practice perspective

Introduction: Newcastle Gateshead is a phase one Targeted Lung Health Checks site. Walker Medical Group GP practice serves a deprived population and is a designated Deep End practice. We report on the experience of Targeted Lung Health Checks at this practice. Method(s): Invitations were sent to eligible participants registered at the practice. Lung health checks were carried out by telephone according to Standard Protocol in the context of the COVID 19 pandemic. Those meeting criteria for Low Dose CT were invited to a mobile scanner located in the community near to the practice. Scans were reported according to the Standard Protocol. Result(s): Of 1481 eligible patients, 736 (50.44%) attended a telephone lung health check. 458 (63.6%) met criteria for a CT scan, of whom 33 declined a scan and 2 were unable to lie flat. 11 lung cancers (2.6%) and one other cancer were diagnosed. 71 (16.8%) had nodules requiring follow-up. These cases were managed by the TLHC programme and lung cancer MDT. Incidental findings had the greatest impact on general practice. 72.3% of scans showed coronary artery calcification. Of these, over 1 in 4 was not currently prescribed a Statin. New diagnoses of bronchiectasis (8 patients = 2%) and interstitial lung disease (7 patients = 1.6%) required GP action. 5 new cases of undiagnosed thoracic aortic aneurysm were identified, requiring referral for further action (1%). Conclusion(s): Incidental findings of Targeted Lung Health Checks CT scans require substantial input from a GP team. Coronary artery calcification is numerically most significant. Participants and practices should be supported by information and resources. Thoracic aortic aneurysm cases are also found in significant numbers and TLHC projects are advised to work with cardiology and cardiac surgery units when setting up. We plan to explore the reasons for participant refusal of CT scanning. Disclosure: No significant relationships.Copyright © 2023 Elsevier B.V.

Complications Of A Severe Case Of Multisystem Inflammatory Syndrome In Children

Case Presentation: A 10 year old male with prior COVID-19 exposure presented with 7 days of fever, rash, cough, vomiting, and hypotension. Laboratory evaluation was notable for SARS-CoV2 antibodies, elevated cardiac enzymes, BNP, and inflammatory markers. Initial echocardiogram showed normal cardiac function and a small LAD coronary aneurysm. He was diagnosed with Multisystemic Inflammatory Syndrome in Children (MIS-C) and given methylprednisolone and IVIG. Within 24 hours, he developed severe LV dysfunction and progressive cardiorespiratory failure requiring VA-ECMO cannulation and anticoagulation with bivalirudin. Cardiac biopsy demonstrated lymphocytic infiltration consistent with myocarditis. On VA-ECMO, he had transient periods of complete AV block. With immunomodulator treatment (anakinra, infliximab) and 5 days of plasmapheresis, inflammatory symptoms and cardiac function improved. He weaned off ECMO, and anticoagulation was transitioned to enoxaparin. He had left sided weakness 5 days later, and brain MRI revealed an MCA infarct. Ten days later, he had focal right sided weakness and repeat MRI showed multiple hemorrhagic cortical lesions, thought to be thromboembolic with hemorrhagic conversion secondary to an exaggerated inflammatory response to an MSSA bacteremia in the setting of MIS-C. Enoxaparin was discontinued. After continued recovery and a slow anakinra and steroid wean, he has normal coronary arteries, cardiac function, and baseline ECG but requires ongoing neurorehabilitation. Discussion(s): COVID-19 infection in children is often mild, but MIS-C is an evolving entity that can present with a wide range of features and severity. This case highlights two concepts. While first degree AV block is often reported in MIS-C, there is potential for progression to advanced AV block. Close telemetry monitoring is critical, especially if there is evidence of myocarditis. MIS-C shares features with Kawasaki disease, with a notable difference being a higher likelihood of shock and cardiac dysfunction in MIS-C. In MIS-C patients with cardiovascular collapse requiring ECMO, there is a risk for stroke. There should be a low threshold for neuroimaging and multidisciplinary effort to guide anticoagulation in these complex cases.

Epidemiologic Characteristics of Multisystem Inflammatory Syndrome in Children (Mis-C) with a Focus on Outcomes

Purpose of Study Treatment outcomes of children diagnosed with MIS-C are unclear and warrant investigation. The purpose of this study is to investigate the characteristics of pediatric patients diagnosed with MIS-C and their treatment outcomes with an emphasis on fatalities associated with MISC. Methods Used A literature review using Google Scholar and Pubmed using keywords such as 'Multisystem Inflammatory Syndrome in Children', 'Pediatric Inflammatory Multisystem Syndrome', and 'Coronavirus Disease 2019' was conducted. We included studies of hospitalized MIS-C patients with a sample size of more than 15. Summary of Results Of ten studies published before August 2020, five reported hospitalized MIS-C cases in the United States and five in Europe. A total of 514 hospitalized patients were reported with a sample size of 15 to 186 in various studies. Of 514 patients, 431 (84%) tested positive for SARS-CoV-2 via RT-PCR or serology. In different studies, 50% to 100% of MIS-C patients required PICU admission, 10% to 54% were intubated, and up to 80% required vasopressors. In studies that reported echocardiogram results, coronary artery dilations or aneurysm were noted in up to 93%, and depressed cardiac function was reported in 51- 100% of MIS-C patients. Treatment of MIS-C patients included intravenous immunoglobulins (IVIG) 388/514 (75%) plus steroids 288/514 (56%), along with anticoagulants and Anakinra 26/514 (5%). In total, 23 patients were put on ECMO, and of those, 16 (70%) survived. The larger studies reported fatality rate of 2% to 3% in hospitalized MIS-C patients. A total of 10 deaths were reported. Of the fatality causes that were described, 3 were associated with cerebral infarction after ECMO, 2 had not received IVIG, systemic glucocorticoids, or immunomodulators, and another 2 had co-morbidities. Conclusions Our review suggests that children with MIS-C who are hospitalized typically have a severe disease course. The outcome in vast majority of patients is favorable but death can occur, most likely as a result of cardiac dysfunction or cerebral infarction. Larger studies are needed to identify clinical features as well as laboratory and diagnostic parameters that predict disease severity and outcome.

Incidental tomographic findings in patients with a Confirmed Diagnosis of COVID-19: An Observational Study

Objective: Describe incidental tomographic in the sample, correlating them with risk factors for chest diseases and sociodemographic data. Method(s): This is a retrospective and observational study covering 162 patients admitted to the COVID sector of the HU/UFJF, from April 1, 2020, to July 7, 2021, with a confirmed laboratory diagnosis of COVID-19. The variables were described in absolute and relative frequencies. The comparison of the correlation between the outcome variable (the tomographic findings) for independent samples was performed using Pearson's chi-square test (without correction) or Fisher's test when relevant. Result(s): Of the 162 patients, 15.4% had a solitary pulmonary nodule;14.8% had multiple pulmonary nodules;1.8%, lung mass;3.1%, mediastinal mass, and 9.3% had mediastinal adenomegaly. Findings such as excavations, pleural effusion, emphysema, PTE, pneumothorax, chronic interstitial disease, cavitation, aneurysms, and significant atheromatosis, classified in this study in the "Other" category showed impressive results, with an overall prevalence of 81.5%. This study demonstrated that 34% of patients had two or more types of incidental CT findings and that 88.3% of patients had at least some type of incidental CT finding. Conclusion(s): The pandemic of SARS-CoV-2 infections has brought a series of challenges and lessons learned to healthcare teams around the world. The massive implementation of highly sensitive diagnostic methods, such as chest tomography, ends up bringing an additional challenge, which is to deal with incidental findings, making good clinical reasoning necessary to avoid unnecessary investigations and not leave without diagnosis and treatment of diseases in early and asymptomatic stages.Copyright © 2023 Faculdade de Medicina de Ribeirao Preto - U.S.P.. All rights reserved.

Atrio-Ventricular Conduction Abnormalities in Multisystem Inflammatory Syndrome in Children

Purpose of study Since mid-April 2020 in Europe and North America, clusters of pediatric cases with a newly described severe systemic inflammatory response with shock have appeared. Patients had persistent fevers >38.5 C, hypotension, features of myocardial dysfunction, coagulopathy, gastrointestinal symptoms, rash, and elevated inflammatory markers without other causes of infection. The World Health Organization, Centers for Disease Control, and Royal College of Paediatrics associated these symptoms with SARS-CoV-2 as multisystem inflammatory syndrome in children (MIS-C). Cardiac manifestations include coronary artery aneurysms, left ventricular systolic dysfunction evidenced by elevation of troponin-T (TnT) and pro-B-type naturietic peptide (proBNP), and electrocardiogram (ECG) abnormalities. We report the clinical course of three children with MIS-C while focusing on the unique atrioventricular (AV) conduction abnormalities. Case #1:19-year-old previously healthy Hispanic male presented with abdominal pain, fever, and non-bloody diarrhea for three days. He was febrile and hypotensive (80/47 mmHg) requiring fluid resuscitation. Symptoms, lab findings, and a positive COVID-19 antibody test were consistent with MIS-C. Methylprednisolone, intravenous immunoglobulin (IVIG), and enoxaparin were started. He required epinephrine for shock and high flow nasal cannula for respiratory distress. Initial echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40% with normal appearing coronaries. Troponin and proBNP were 0.41 ng/mL and proBNP 15,301 pg/mL respectively. ECG showed an incomplete right bundle branch block. He eventually became bradycardic to the 30s-50s and cardiac tracing revealed a complete AV block (figure 1a). Isoproterenol, a B1 receptor agonist, supported the severe bradycardia until the patient progressed to a type 2 second degree AV block (figure 1b). A second dose of IVIG was administered improving the rhythm to a type 1 second degree AV block. An IL-6 inhibitor, tocilizumab was given as the rhythm would not improve, and the patient soon converted to a first-degree AV block. Cardiac magnetic resonance imaging showed septal predominant left ventricular hypertrophy and subepicardial enhancement along the basal inferior/anteroseptal walls typical for myocarditis. Case #2: 9-year-old previously healthy Hispanic male presented after three days of daily fevers, headaches, myalgias, diffuse abdominal pain, and ageusia. He was febrile, tachycardic, and hypotensive (68/39 mmHg). Hypotension of 50s/20s mmHg required 3 normal saline boluses of 20 ml/kg and initiation of an epinephrine drip. Severe hypoxia required endotracheal intubation. After the MIS-C diagnosis was made, he was treated with IVIG, mehtylprednisolone, enoxaparin, aspirin, and ceftriaxone. Due to elevated inflammatory markers by day 4 and patient's illness severity, a 7-day course of anakinra was initiated. Initial echocardiogram showed mild tricuspid and mitral regurgitation with a LVEF of 35-40%. Despite anti-inflammatory therapy, troponin and proBNP were 0.33 ng/mL and BNP of 25,335 pg/mL. A second echocardiogram confirmed poor function so milrinone was started. Only, after two doses of anakinra, LVEF soon normalized. Despite that, he progressively became bradycardic to the 50's. QTc was prolonged to 545 ms and worsened to a max of 592 ms. The aforementioned therapies were continued, and the bradycardia and QTc improved to 405 ms. Patient #3: 9-year-old African American male presented with four days of right sided abdominal pain, constipation, and non-bilious non-bloody emesis. He had a negative COVID test and unremarkable ultrasound of the appendix days prior. His history, elevated inflammatory markers, and positive COVID- 19 antibody were indicative of MIS-C. He was started on the appropriate medication regimen. Initial ECG showed sinus rhythm with normal intervals and echocardiogram was unremarkable. Repeat imaging by day three showed a decreased LVEF of 50%. ECG had since changed to a right bundle branch block. Anakinra as started and steroid dosing was increased. By day 5, he became bradycardic to the 50s and progressed to a junctional cardiac rhythm. Cardiac function normalized by day 7, and anakinra was subsequently stopped. Thereafter, heart rates ranged from 38-48 bpm requiring transfer to the pediatric cardiac intensive care unit for better monitoring and potential isoproterenol infusion. He remained well perfused, with continued medical management, heart rates improved. Methods used Retrospective Chart Review. Summary of results Non-specific T-wave, ST segment changes, and premature atrial or ventricular beats are the most often noted ECG anomalies. All patients initially had normal ECGs but developed bradycardia followed by either PR prolongation or QTc elongation. Two had mild LVEF dysfunction prior to developing third degree heart block and/or a junctional escape rhythm;one had moderate LVEF dysfunction that normalized before developing a prolonged QTc. Inflammatory and cardiac markers along with coagulation factors were the highest early in disease course, peak BNP occurred at approximately hospital day 3-4, and patient's typically had their lowest LVEF at day 5-6. Initial ECGs were benign with PR intervals below 200 milliseconds (ms). Collectively the length of time from initial symptom presentation till when ECG abnormalities began tended to be at day 8-9. Patients similarly developed increased QTc intervals later in the hospitalization. When comparing with the CRP and BNP trends, it appeared that the ECG changes (including PR and QTc elongation) occurred after the initial hyperinflammatory response. Conclusions Although the mechanism for COVID-19 induced heart block continues to be studied, it is suspected to be secondary to inflammation and edema of the conduction tissue. Insufficiency of the coronary arterial supply to the AV node and rest of the conduction system also seems to play a role. Although our patients had normal ECG findings, two developed bundle branch blocks prior to more complex rhythms near the peak of inflammatory marker values. Based on the premise that MIS-C is a hyperinflammatory response likely affecting conduction tissue, our group was treated with different regimens of IVIG, steroids, anakinra, and/or tocilizumab. Anakinra, being an IL-1 inhibitor, has been reported to dampen inflammation in viral myocarditis and tocilizumab has improved LVEF in rheumatoid arthritis patients. Based on our small case series, patient's with MISC can have AV nodal conduction abnormalities. The usual cocktail of IVIG and steroids helps;however, when there are more serious cases of cardiac inflammation, adjuvant immunosuppresants like anakinra and toculizumab can be beneficial. (Figure Presented).

Protocol for the Metformin Aneurysm Trial (MAT): a placebo-controlled randomised trial testing whether metformin reduces the risk of serious complications of abdominal aortic aneurysm.

BACKGROUND: Multiple observational studies have associated metformin prescription with reduced progression of abdominal aortic aneurysm (AAA). The Metformin Aneurysm Trial (MAT) will test whether metformin reduces the risk of AAA rupture-related mortality or requirement for AAA surgery (AAA events) in people with asymptomatic aneurysms. METHODS: MAT is an international, multi-centre, prospective, parallel-group, randomised, placebo-controlled trial. Participants must have an asymptomatic AAA measuring at least 35 mm in maximum diameter, no diabetes, no contraindication to metformin and no current plans for surgical repair. The double-blind period is preceded by a 6-week, single-blind, active run-in phase in which all potential participants receive metformin. Only patients tolerating metformin by taking at least 80% of allocated medication will enter the trial and be randomised to 1500 mg of metformin XR or an identical placebo. The primary outcome is the proportion of AAA events defined as rupture-related mortality or need for surgical repair. Secondary outcomes include AAA growth, major adverse cardiovascular events and health-related quality of life. In order to test if metformin reduced the risk of AAA events by at least 25%, 616 primary outcome events will be required (power 90%, alpha 0.05). DISCUSSION: Currently, there is no drug therapy for AAA. Past trials have found no convincing evidence of the benefit of multiple blood pressure lowering, antibiotics, a mast cell inhibitor, an anti-platelet drug and a lipid-lowering medication on AAA growth. MAT is one of a number of trials now ongoing testing metformin for AAA. MAT, unlike these other trials, is designed to test the effect of metformin on AAA events. The international collaboration needed for MAT will be challenging to achieve given the current COVID-19 pandemic. If this challenge can be overcome, MAT will represent a trial unique within the AAA field in its large size and design. TRIAL REGISTRATION: Australian Clinical Trials ACTRN12618001707257 . Registered on 16 October 2018.

Multisystemic Inflammatory Syndrome in Children and Kawasaki Disease: Parallels in Pathogenesis and Treatment.

PURPOSE OF REVIEW: Since it first appeared, multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) has been compared to Kawasaki disease (KD). Although there were early parallels between MIS-C and KD, key differences emerged over time. Here, we aim to compare the pathogenesis, clinical presentation, treatment, and outcomes of MIS-C and KD. RECENT FINDINGS: In this article, we review and compare MIS-C and KD, highlighting differentiating features. We discuss the epidemiological and immunological factors along with clinical and laboratory features which discern MIS-C from KD. We also compare treatment and our understanding of long-term outcomes. Though parallels exist between MIS-C and KD, distinguishing the two is important for clinical management of patients, counseling about natural history, and determining long-term monitoring. While both MIS-C and KD are characterized by profound inflammation and inflammatory vasculopathy, further study is needed to determine whether they are distinct immunopathogenic disorders.

Bioinformatics approach to analyse COVID-19 biomarkers accountable for generation of intracranial aneurysm in COVID-19 patients.

COVID-19 became a health emergency on January 30, 2020. SARS-CoV-2 is the causative agent of the coronavirus disease known as COVID-19 and can develop cardiometabolic and neurological disorders. Intracranial aneurysm (IA) is considered the most significant reason for hemorrhagic stroke,and it accounts for approximately 85% of all subarachnoid hemorrhages (SAH). Retinoid signaling abnormalities may explain COVID-19's pathogenesis with inhibition of AEH2, from which COVID-19 infection may enhance aneurysm formation and rupture due to abrupt blood pressure changes, endothelial cell injury, and systemic inflammation. The objective of this study was to investigate the potential biomarkers, differentially expressed genes (DEGs), and metabolic pathways associated with both COVID-19 and intracranial aneurysm (IA) using simulation databases like DIsGeNET. The purpose was to confirm prior findings and gain a comprehensive understanding of the underlying mechanisms that contribute to the development of these conditions. We combined the regulated genes to describe intracranial aneurysm formation in COVID-19. To determine DEGs in COVID-19 and IA patient tissues, we compared gene expression transcriptomic datasets from healthy and diseased individuals. There were 41 differentially expressed genes (DEGs) shared by both the COVID-19 and IA datasets (27 up-regulated genes and 14 down-regulated genes). Using protein-protein interaction analysis, we were able to identify hub proteins (C3, NCR1, IL10RA, OXTR, RSAD2, CD38, IL10RB, MX1, IL10, GFAP, IFIT3, XAF1, USP18, OASL, IFI6, EPSTI1, CMPK2, and ISG15), which were not described as key proteins for both COVID-19 and IA before. We also used Gene Ontology analysis (6 significant ontologies were validated), Pathway analysis (the top 20 were validated), TF-Gene interaction analysis, Gene miRNA analysis, and Drug-Protein interaction analysis methods to comprehend the extensive connection between COVID-19 and IA. In Drug-Protein interaction analysis, we have gotten the following three drugs: LLL-3348, CRx139, and AV41 against IL10 which was both common for COVID-19 and IA disease. Our study with different cabalistic methods has showed the interaction between the proteins and pathways with drug analysis which may direct further treatment development for certain diseases.