Enoxaparin Sodium Biosimilar in the Prophylactic Treatment of Veinous Thromboembolism and Thromboembolic Disease: Prophyvar Study

Objectives: Varenox is the first locally manufactured and approved biosimilar in Algeria. It is an enoxaparin sodium (ES) with established good analytical characterization and manufacturing quality control. The aim of the PROPHYVAR study was to generate real-life data in routine practices and to assess the safety and tolerability in the prophylaxis of venous thromboembolism (VTE). Method(s): This is an observational, prospective, multicenter study, conducted between April 2021 and May 2022. The primary safety outcome was the incidence of Adverse Events (AEs) related to the study drug. A sample size of 500 patients was calculated to estimate the proportion of patients with AEs. Assuming that approximately 10% will be lost to follow-up or not evaluable, 550 patients were needed to describe the impact of Varenox use. Result(s): The study was conducted in 25 different sites in Algeria, in 4 therapeutic areas: ICU, orthopedic surgery, obstetrics and nephrology;550 patients were included and received at least one injection of Varenox. The mean age was 47 years, women in majority (62.5%). The patients were overweight or obese (53%), with a history of arterial hypertension (25%), diabetes (7.5%) and renal failure (6.4%). Reasons for hospitalization were mainly fracture (15.5%), pregnancy (8.3%), COVID-19 (7%) or cancer (7%). The majority of patients were treated at prophylactic dose of 0.4ml (80%) or 0.6ml (10%). The median duration of follow-up was 24 days. A total of 38 patients experienced at least one AE (6.9%, CI95=[4.9%;9.4%]). Related AEs were reported in 10 patients (1.8%), mainly in nephrology (N=7 arterio-venous fistula). VTE events were reported in 6 patients (1.1%, CI95=[0.2%;2%]). Conclusion(s): This study suggests that Varenox is safe in the prophylaxis of VTE. To our knowledge this is the first large study describing the use of ES in current medical practice in Algeria.Copyright © 2023

A baby girl with TBX1 haploinsufficiency who died after elective cardiac repair surgery due to suspected enteroviral meningitis

Introduction: TBX1 haploinsufficiency is an inborn error of immunity with the phenotype of DiGeorge Syndrome. DiGeorge Syndrome has variable immunodeficiency associated with grade of thymic hypoplasia ranging from mild with no infections to severe requiring thymus implant. Enterovirus is an example of an opportunistic infection that can be fatal in these patients. Case Presentation: A 1 year old girl with TBX1 haploinsufficiency complicated by Tetralogy of Fallot, pulmonary atresia, high arched palate, and vesicovaginal fistula presented for elective cardiac repair surgery from another country due to failure to thrive and cyanosis. She had no prior infectious history but was on sulfamethoxazole-trimethoprim for prophylaxis. She was asymptomatic with a negative COVID test but no other infectious studies performed. Immediately postoperatively, she was febrile and nasal respiratory viral panel was positive for rhinovirus/enterovirus with increased procalcitonin and leukocytosis with left shift. She decompensated with multi-organ failure and cardiac arrest on postoperative day two. She was cannulated to veno-arterial extracorporeal membrane oxygenation (ECMO). Pre-operatively, she had a normal absolute lymphocyte count. No thymus tissue was observed in surgery. She had profound CD3 lymphopenia to 130 cells/cmm when critically ill. Enteroviral meningitis was suspected as no infectious, cardiac, or other pathology could be identified causing decompensation. Enteroviral serum polymerase chain reaction (PCR) test was negative while lumbar puncture deferred due to clinical status. She was treated with immunoglobulin. Offlabel investigational drug pocapavir was considered but deferred to patient's irreversible neurological status. The patient was disconnected from ECMO and expired. Discussion(s): Though we cannot confirm that this patient had enteroviral meningitis, invasive enteroviral infections are associated with elevated transaminases, coagulopathy, and seizures all present in our patient. There has also been reported negative serum enteroviral PCR but positive CSF enteroviral PCR in an immunodeficient patient. Additionally, this case highlights the importance of immunologic evaluation in patients with DiGeorge Syndrome and questions if asymptomatic viral screening for viruses like enterovirus should be considered pre-operatively in patients with inborn errors of immunity. This case highlights potential treatment options for invasive enteroviral infections in patients with inborn errors of immunity: high dose immunoglobulin, fluoxetine, and pocapavir.Copyright © 2023 Elsevier Inc.

Subacute Enteritis Two Months After COVID-19 Pneumonia With Mucosal Bleeding, Perforation, and Internal Fistulas.

Chronic sequelae of COVID-19 remain undetermined. We report a case of postinfection sequelae in a patient presenting with subacute obstruction 2 months after COVID-19 infection. A 34-year-old man with a prior prolonged hospital stay due to COVID-19 complicated by upper gastrointestinal (GI) bleed presented with subacute obstruction and failure to thrive. Upper GI push enteroscopy revealed residual ulcers and multiple proximal jejuno-jejunal fistulae. Midline laparotomy revealed strictures with dense intra-abdominal adhesions, a large jejuno-jejunal fistula, and evidence of prior jejunal perforation following severe COVID-19 infection. The patient recovered after small bowel resection with anastomoses and was discharged home. Histopathological examination of resected specimen confirmed transmural infarction with evidence of prior hemorrhage, diffuse ulcers, and multifocal inflammation. This is the first report of a chronic GI sequelae resulting from COVID-19. As the pandemic evolves, medical professionals must be vigilant to consider alternative GI diagnoses in the COVID-19 survivors.

Did stopping ultrasound surveillance during COVID-19 result in an increase of the dialysis access thrombosis rate?

PURPOSE: The COVID-19 pandemic resulted in cessation and subsequent reduction of routine care including the outpatient ultrasound surveillance of AVF. This un-planned service disruption allowed evaluation of effectiveness of US surveillance in reducing AVF/AVG thrombosis. METHODS: This study was a secondary data analysis of monthly access patency for all in-centre patients receiving haemodialysis using an AVF or AVG over a 2-year period (April 2019-March 2021). The study included 298 patients with age, access type, patency and COVID status measured as variables. Thrombosis rates for the 12 months prior to COVID-19 and then during the first 12 months of the pandemic were also measured. Statistical analysis to assess mean and standard deviation for relevant variables was used. A p-value of <0.05 was deemed significant. RESULTS: At the end of the study an increase in thrombosis rate (%) in the non-surveillance year was observed ((1.20) thrombosis/patient/year in the surveillance group vs (1.68) thrombosis/patient/year in the non-surveillance group). Monthly mean of thrombosed access during surveillance (M = 3.58, 95% CI 2.19-4.98, SD = 2.193) and non-surveillance (M = 4.92, 95% CI 3.52-6.31, SD = 2.19); t(7148) = 2.051, p = 0.038. CONCLUSION: Reduction in routine Ultrasound surveillance following the COVID-19 pandemic was associated with a significant increase in access thrombosis rate. Further research is needed to unpick whether the associations seen were directly due to service changes, associated with COVID-19 or other factors during the pandemic. This association was independent of SARS-CoV-2 infection status. Clinical teams should consider alternative service delivery options including out-reach, bedside surveillance to balance risks of access thrombosis versus reducing the risk of nosocomial infection with hospital visits.

Pseudomyxoma peritonei - Jelly Belly: To Tap or Not

Introduction: Mucinous adenocarcinomas of the appendix are defined as epithelial neoplasms often causing cystic dilation of the appendix due to accumulation of gelatinous material. Pseudomyxoma peritonei is an extremely rare complication of appendiceal mucinous adenocarcinomas with an estimated incidence rate of one to 2 people per million per year. Here-in we present a unique case of enterocutaneous fistula formation secondary to percutaneous biopsy of an enlarging omental mass in the setting of pseudomyxoma peritonei. Case Description/Methods: A 50-year-old male with a past medical history of metastatic appendiceal mucinous adenocarcinoma presented to the ED with abdominal pain, nausea, and vomiting. The patient had previously undergone 2 debulking surgeries over the past 2 years prior to admission and has since been on FOLFOX therapy. Due to the COVID pandemic, the patient did not follow-up in the 2 years period from previous admission. A CT scan was now notable for a new enlarging omental mass despite the recent debulking surgery. Given the enlarging mass, a decision was made to pursue a percutaneous biopsy of the mass due to concern for potential new malignancy. Two weeks after the biopsy, the patient presented to our facility due to worsening erythema and drainage from the biopsy site. The patient met SIRS criteria, thus broad-spectrum antibiotics were initiated. A CT of the abdomen and pelvis with oral and IV contrast was obtained, which demonstrated a 9 cm abscess or continuation of intra-abdominal multilocular cystic lesion/ pseudomyxoma peritonei. The surgical team was consulted. Patient had 100 cc of purulent and mucinous drainage expressed from biopsy site. The patient was then placed for transfer to a hospital capable of advanced surgical management for evaluation and potential resection of fistula formation. The patient had a successful reductive surgery and intraoperative chemotherapy (Figure). Discussion(s): Given the rarity of pseudomyxoma peritonei, appropriate management is not always straightforward. A literature review yielded no previous reports of enterocutaneous fistula as a complication of percutaneous drainage in the setting of pseudomyxoma peritonei. We recommend that percutaneous drainage not be sought in individuals with this diagnosis due to potential for fistula formation.

Micronutrients Deficiency in Patients Receiving Parenteral Nutrition: Effect of Multivitamin Supply Shortage

Background: Total parenteral nutrition (TPN) is a life-saving therapy for patients with chronic intestinal failure. TPN typically consists of macronutrients (amino acids, dextrose, and lipids) as well as micronutrients (multi-vitamins [MVI] and trace elements) to meet fluid, calorie, and micronutrient needs. With the early years of PN administration, multiple deficiencies were noted leading to guidelines regarding need for daily use of essential trace element and MVI preparation for parenteral use. Unfortunately, during the last few years we have seen multiple shortages of PN related supplies including the most recent shortage of parenteral MVI preparation. Major organizations such as ASPEN have developed recommendations regarding management of shortages, however their clinical impact has not been fully evaluated. The current study evaluated the impact of MVI shortage on change in clinical practice and the prevalence of deficiency. Method(s): A retrospective review of electronic medical records for patients who received TPN during time of shortage in IV multivitamins supply due to COVID-19 crisis between January 2021 and June 2021. In our program, the shortage affected one TPN supplier. We included patients who received their TPN from affected supplier and who were tested for micronutrients including Vitamins A, B12, C, and D in the 6 months preceding the shortage in supply (period 1) as well as during the shortage period (period 2). Period 1 was defined as from July 1, 2020, to December 31, 2020, and period 2 was defined as from January 1, 2021, to June 30, 2021. In addition to baseline clinical characteristics, we captured changes in studied micronutrients. Result(s): Current retrospective analysis of a prospectively maintained database noted 21 patients (mean age of 63.3 +/- 13.8, 62% female) were impacted by MVI shortage during study period (Table 1). Most common primary diagnosis was Crohn's disease (33.3%) followed by enterocutaneous fistula (19%), and gastrointestinal dysmotility (14.3%). In 19/21 (90%) patients, MVI was administered 3 days per week in PN. In the remaining two patients who had short bowel,MVI was continued 7 days per week. Additionally, 19/21 (90%) patients also were supplemented orally with Vitamin D (17/21), Vitamin B12 (5/21), MVI (3/21), Vitamin C (1/21). There was a decline in average Vitamin C levels between the two study periods (Table 2) with a trend towards a decline in average 25-hydroxy vitamin D levels, while mean vitamin A and B12 levels did not change significantly. There was a significant increase in Vitamin D and C deficiencies, while no increase in deficiencies in Vitamin E, A, and B12 levels was noted (Figure 1). Conclusion(s): Unfortunately, shortages of key PN related supplies have become commonplace in the last few years. The most recent shortage affected MVI supplies. Our group managed the shortage through a combination of reduction of parenteral MVI administration to 3 days per week along with additional supplementation of specific micronutrients orally. Although with this strategy, there was an increase in Vitamin D and C levels falling below reference range, no significant deficiencies were noted. (Table Presented).

Tracheoesophageal Fistula Presenting With Gastrostomy Tube Pressurization

Introduction: Patients with COVID pneumonia who require intubation and prolonged mechanical ventilation are at risk for complications such as recurrent infection, tracheomalacia, tracheal stenosis, and the development of tracheoesophageal fistula (TEF). TEF is a devastating complication where the trachea and esophagus develop an abnormal connection in the lower airway that dramatically increases the mortality of critically ill patients by recurrent aspiration and pneumonias. Though commonly associated with neoplasms another risk is pressure induced ischemia of the common wall between the trachea and esophagus. This can occur due to overinflation of the endotracheal (ET) cuff, especially with concomitant use of a nasogastric tube (NGT). Definitive management requires surgical repair. Case Description/Methods: A 69-year-old male patient presented with acute hypoxemic respiratory failure secondary to COVID pneumonia requiring intubation and insertion of an NGT. On day 29 the patient underwent percutaneous enterogastrostomy (PEG) placement and tracheostomy;it was noted intraoperatively that the tracheal mucosa was inflamed and friable. On day 36 bronchoscopy was performed through the tracheostomy tube due to concerns for mucus plugging. Friable mucosa with granulation tissue was seen at the distal end of the tube, so an extra-long tracheostomy tube was exchanged to bypass the granulation tissue. Later that night the ventilator measured a 50% discrepancy between the delivered and exhaled tidal volumes, triggering an alarm. Exam noted distension of the PEG-bag with a fluid meniscus in the tubing moving in sync with each respiration. TEF was considered and bronchoscopic evaluation confirmed a 1-centimeter TEF. The patient underwent successful TEF repair and is slowly recovering (Figure). Discussion(s): Critically ill patients who require prolonged support are at high risk of complications and device related injury. With each device-day there is an increased risk of complications, such as infection, dislodgement, and pressure-related injuries. This case highlights the importance of serial physical examinations as well as understanding possible device related complications. An unexpected finding, such as a persistent air leak, air in a PEG bag, or a fluctuating meniscus should raise suspicion for the development of a serious complication and would warrant prompt confirmatory testing. Our literature review revealed no reports of a PEG tube abnormalities as a presenting finding for TEF.

Spontaneous Gastro-pancreatic Fistula: A Rare Complication of Acute Pancreatitis

Introduction: Although Gastrointestinal fistula is a well-recognized complication of acute pancreatitis, it has been rarely reported. Here we present a rare case of spontaneous gastro-pancreatic fistula following acute pancreatitis. Case Description/Methods: 42 y/o female with PMH of SLE with a recent prolonged hospitalization for acute drug-induced pancreatitis with pseudocyst came to ED with fever, abdominal pain, nausea, and vomiting. She was tachycardic, had leukocytosis, and was positive for COVID-19. CT Scan A/P showed multiple infected peripancreatic collections with communication of the left upper quadrant collection with the gastric lumen (Figure). The patient was hospitalized, Kept NPO, and started on fluids and antibiotics. IR evaluated and put 2 pigtail catheters for drainage of peripancreatic collections. The tip of the pigtail catheter in the left peripancreatic/retroperitoneal collection was in the gastric lumen. The surgery team recommended continuing with conservative treatment with parenteral nutrition, and IV antibiotics as the patient were nontoxic with no signs of free perforation, and pancreatitis would more likely erode a staple or suture line and would put the patient at further risk of free perforation if repair attempted. IR was successful in pulling the drain out of the gastric lumen on the second attempt to allow gastric perforation to heal. Antibiotics were upgraded as per the culture and sensitivity results of the drain fluid. Repeated multiple bedside leak tests and CT scans with oral contrast continue to be positive for patent gastro-pancreatic fistula. Pigtails catheter continues to drain significant necrotic collection. The patient continues to be hospitalized and is being managed conservatively with Parenteral nutrition, and IV antibiotics. Discussion(s): Fistula of the GI tract following acute pancreatitis can be caused by multiple reasons. Necrosis of the bowel may occur concomitantly with the pancreatic or peripancreatic tissue. Furthermore, enzyme-rich fluid and necrosis can lead to vascular thrombosis, which compromises the blood supply of the segmental GI tract, eventually leading to bowel necrosis. GI fistulas are more common in patients with necrotizing pancreatitis with infected pancreatic necrosis. Despite pharmacologic suppression of pancreatic exocrine secretion and advances in endoscopic and percutaneous therapeutic techniques, pancreatic fistula continues to be a source of morbidity and mortality following pancreatitis and requires multidisciplinary treatment.

Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

Recent Trends and Characteristics of Genitourinary Fistulas in Rwanda

INTRODUCTION AND OBJECTIVE: Genitourinary fistulas (GU) in Rwanda have significantly increased in recent years. We previously reported an increase in the proportion of vesicouterine, vesicocervical and uterovaginal fistulas, with the majority occurring after Cesarean section. Our goal is to examine the characteristics of our the most recent cohort. METHOD(S): A cross-sectional study was conducted of women presenting for evaluation to the International Organization for Women and Development (IWOD) in Kigali, Rwanda, from 2018 to 2019, and 2022. No data was collected during years 2020 and 2021, due to the COVID-19 pandemic. Data was collected from medical records and included region of residence, surgical history, presence of fistula, and type. RESULT(S): A total of 434 women were evaluated, of these 194 (44.7%) were diagnosed with GU fistula. In 2018, fistula types were 40 (52%) vesicovaginal, 5 (6%) urethral, 5 (6%) ureterovaginal, 23 (30%) vesicoureterine or vesicocervical, and 7 (9%) juxtacervical. In 2019, the fistula types were 26 (41%) vesicovaginal, 4 (6%) urethral, 6 (10%) ureterovaginal, 17 (27%) vesicoureterine or vesicocervical, and 10 (16%) juxtacervical. In 2022, the fistula types were 33 (61%) vesicovaginal, no urethral fistula reported, 7 (13%) ureterovaginal, 8 (15%) vesicoureterine or vesicocervical, and 6 (11%) juxtacervical. CONCLUSION(S): In comparison to our prior cohort, recent data shows a stable proportion of types of fistulas. The increased number of vesicouterine, vesicocervical, and juxtacervical fistula may be higher due to increased performance of Cesarean sections.

From Covid to Bovid to Ovid: A Case of Disseminated Cryptococcus Neoformans

Case Report: Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus, with C. neoformans and C. gattii being the most common species to cause human disease. Immunocompromised individuals are predisposed to infections with C. neoformans, which has known predilection to CNS and pulmonary lymph nodes. We present a unique case of disseminated cryptococcosis in the setting of end-stage renal disease (ESRD), cirrhosis, tumor necrosis factor inhibitor use and steroid use for COVID19. Method(s): A single-patient case report was conducted after IRB approval. Case Presentation: A 55-year-old woman with uncontrolled diabetes, lupus, rheumatoid arthritis on adalimumab, hepatitis C status post boceprevir, cirrhosis, former IV drug use, and ESRD on hemodialysis via bovine arterial-venous fistula graft presented with worsening dyspnea, cough, and altered mental status. Three months prior, patient was admitted to an outside hospital for COVID19, complicated by pulmonary embolism status post anticoagulation therapy. Patient was treated with an unknown steroid regimen, which was continued by a second outside facility when symptoms failed to improve. Patient then presented to our facility 24 hours after discharge due to continued symptoms. On admission, patient was noted to have altered mentation and hypoxia with pulmonary edema on chest x-ray and was urgently hemodialyzed. Further work-up was obtained due to non-resolving symptoms, including blood and sputum cultures, cocci serology and QuantiFERON gold. CT chest revealed bilateral consolidations. Patient was started on antibiotics for presumed hospital-acquired pneumonia. During the hospital stay, preliminarily blood cultures grew yeast and patient was started on Micafungin. However, Micafungin was changed to Liposomal Amphotericin B as ovoid structures seen on gram stain could not confirm nor rule out cryptococcus. Subsequent bronchial wash and bronchoalveolar lavage cultures, as well as final blood cultures resulted Cryptococcus neoformans. Serum cryptococcus antigen returned reactive, titer 1:512. Antibiotics were discontinued and Isavuconazonium was started with Liposomal Amphotericin B. Due to recurrent headaches, lumbar puncture was obtained and revealed lymphocytic pleocytosis without cryptococcal antigenicity. Patient completed 14 days of Liposomal Amphotericin B and Isavuconazole with continuation of Isavuconazole upon discharge. Conclusion(s): Disseminated cryptococcosis in non-HIV patients is rare in the modern HIV era. Clinicians should be aware and include it in their differential of any patient with multiple risk factors for opportunistic infection. In patients with cirrhosis and ESRD, treatment is limited given altered pharmacokinetics. Studies have shown improved survival with the addition of Isavuconazole in patients with disseminated cryptococcosis with CNS involvement in the setting of chronic liver disease and ESRD.

Jahrestagung der Gesellschaft fur Padiatrische Pneumologie.

The proceedings contain 54 papers. The topics discussed include: cytokines in severe childhood asthma;transcriptional gene regulation of interleukin-6 in epithelial cells in viral-induced asthma exacerbation;assessment of the long-term safety and efficacy of dupilumab in children with asthma: LIBERTY ASTHMA EXCURSION;impulse oscillometry bronchodilator response in preschool children;pulmonary function in non-hospitalized adults and children after mild Covid-19;exhaled aerosols in PCR-confirmed SARS-CoV-2-infected children;early respiratory infectious diseases have an influence on the gut microbiome;comparison of three eradication treatment protocols for pseudomonas aeruginosa in children and adolescents with cystic fibrosis;neutrophilic airway inflammation in children with repaired esophageal atresia-tracheoesophageal fistula (EA/TEF);and multiplex immunofluorescence and multispectral imaging as a tool to evaluate host directed therapy.

Implications of COVID-19 Infection on Arteriovenous Fistula Thrombosis.

Objective: This study aims to identify and analyze implications of COVID-19 positivity on AVF occlusion, subsequent treatment patterns, and ESRD patient outcomes. Our aim is to provide a quantitative context for vascular access surgeons in order to optimize surgical decision making and minimize patient morbidity. Methods: The de-identified national TriNetX database was queried to extracted all adult patients who had a known AVF between January 1, 2020 and December 31, 2021. From this cohort individuals who also were diagnosed with COVID-19 prior to creation of their AVF were identified. Cohorts were propensity score matched according to age at AVF surgery, gender, ethnicity, diabetes mellitus, nicotine dependence, tobacco use, use of anticoagulant medications, and use of platelet aggregation inhibitors, hypertensive diseases, hyperlipidemia, and prothrombotic states. Results: After propensity score matching there were 5170 patients; 2585 patients in each group. The total patient population had 3023 (58.5%) males and 2147 (41.5%) females. The overall rate of thrombosis of AV fistulas was 300 (11.6%) in the cohort with COVID-19 and 256 (9.9%) in the control group (OR 1.199, CI 1.005-1.43, P =.0453). Open revisions of AVF with thrombectomy were significantly higher in the COVID-19 cohort compared to the non-COVID-19 group (1.5% vs .5% P = .0002, OR 3.199, CI 1.668-6.136). Regarding the time from AVF creation to intervention, the median days for open thrombectomy in COVID-19 patients was 72 vs 105 days in controls. For endovascular thrombectomy, the median was 175 vs 168 days for the COVID-19 and control cohorts respectively. Conclusion: As for this study, there were significant differences in rates of thrombosis and open revisions of recent created AVF, however endovascular interventions remained remarkably low. As noted in this study, the persistent prothrombotic state of patients with a history of COVID-19 may persist beyond the acute infectious period of the disease.

Radiologic and Endoscopic Treatment for a Disconnected Pancreatic Duct Syndrome Associated to Percutaneous Pancreatic Fistula: Achieving the "Internalization of the Fistula"

Background and aim: A 40-year-old male was referred to our institute for the management of a percutaneous pancreatic fistula after acute pancreatitis due to SARS-COV2 infection. He developed a peripancreatic collection(PPC) which was percutaneously drained due to infection. After the resolution of PPC, a percutaneous leakage of the main pancreatic duct (MPD) was observed, so he underwent Endoscopic Retrograde ColangioPancreatography(ERCP) with biliary plus pancreatic sphincterotomy and placement of both pancreatic and biliary stent without resolution of the leak. Material(s) and Method(s): Then he was referred to our institution, where initial management included ERCP with placement of two trans-papillary pancreatic stents and the removal of percutaneous catheter, but the fistula kept to drain. Result(s): A multidisciplinary-board decided to perform a rendezvous with interventional radiology to facilitate an endoscopic ultrasound(EUS) trans-gastric drainage of the pancreatic area draining in the percutaneous fistula. Conclusion(s): The procedure included an initial ERCP with replacement of the two pancreatic stents while the radiologist places percutaneously a guidewire through the fistula to the pancreatic point of leakage into MPD. After that, EUS identified the point in which the percutaneous guidewire was getting into the MPD and a trans-gastric EUS-guided insertion of a guidewire achieved the MPD through a 19-Gauge needle. The latter guidewire crossed the percutaneous fistula and came out. At that point, a dilation up to 10 mm was performed to create a trans-gastric pancreatic fistula. The next step was to insert percutaneously a double pigtail(10 Fr) releasing the distal side into the stomach and the proximal side into the main pancreatic duct in order to stabilize the neo-fistula. Another trans-gastric plastic stent was endoscopically placed through the pancreato-gastric neo-fistula. At the end, injection of contrast dye through the percutaneous fistula showed a complete drainage into stomach. In conclusion, the procedure achieved the complete exclusion and resolution of the pancreatic-cutaneous fistula.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

Primary proximal hypospadias repair in in toilet-trained males is associated with a higher risk of post-operative complications and parental dissatisfaction

Introduction & Objectives: Hypospadias is the most common congenital malformation of the penis. There has been a lot of recent controversy in certain countries as to whether operating on distal hypospadias is warranted, and when this should occur. Proximal hypospadias, however, is much less common, with a putative aetiology within the male programming window of the first trimester. It has an association with differences of sexual development (DSD) when diagnosed alongside cryptorchidism and the operative approach is technically more challenging. The European Association of Urology (EAU) recommends initial repair between 6-18 months of age. Material(s) and Method(s): We prospectively gathered data from 24 consecutive toilet-trained children (3-7 years) who were initially listed for proximal hypospadias repair, but who were delayed as a result of resource limitations and the ongoing supply chain effects of COVID-19. The patients were operated between July 2020 and July 2022 with a mean follow-up of 7 months (3-24months). These were compared with a cohort of 16 patients who underwent proximal hypospadias repair between 12-18 months of age in the same institution. Both single and staged procedures were included. Institutional review board approval was obtained. Patients who had previously been operated on as an infant, or who were diagnosed with a DSD, or had an associated diagnosed neuropsychiatric developmental disorder were excluded. Pre-, peri- and post-operative data were statistically compared. Result(s): Overall, 40 children underwent a total of 75 primary procedures for their proximal hypospadias (7x single stage;31 x 2-stage;2 x 3-stage). All patients had an indwelling catheter placed post-operatively, were on antibiotic prophylaxis and oxybutynin for bladder spasms. Morphine was not used post-operatively in any case. Apart from age, there were no significant demographic or racial differences between these groups. The toilettrained cohort was associated with a higher rate of urethrocutaneous fistulas (58% vs. 31%;p=0.11), catheter/stent trauma (79% vs. 6%;p<0.001), pain (54% vs. 12%;p<0.01), constipation (75% vs. 37%;p=0.02). Both Likert Scales (4 vs. 8) and parental net promoter scores (-25 vs. +68.75) were worse for the toilet trained cohort compared to the infant cohort. There were no differences in glans dehiscence, or residual chordee between both groups. Conclusion(s): Primary proximal hypospadias repair is associated with a higher degree of perioperative complications in toilet-trained kids and lower levels of parental satisfaction. These cases are not deemed to be suitable to be managed conservatively and should be offered treatment within the 6-18 months window adjusted for gestational age as endorsed by the EAU.Copyright © 2023.

Paravalvular aortic abscess with aorto-left atrial fistula in infective endocarditis of the native aortic valve: a case report

Introduction: Infective endocarditis (IE) is a life-threatening disease with poor prognosis and high mortality if not diagnosed promptly and intervened early1. Perianullary extension accounts for nearly 40% of all native valves IE, most commonly the aortic valve, but formation of an intracardiac fistula occurs in less than 1% of all cases2. Case report: We report the case of a 64-year-old man admitted to the intensive care unit because of acute respiratory failure with high fever, high inflammatory blood reactants and electrolyte disbalance. He had previously been extensively evaluated for microcytic anemia due to hemorrhoids, and had also suffered from epilepsy since his youth. A series of blood cultures were obtained and Streptococcus oralis was positive. Because of systolic-diastolic murmur and second-degree atrioventricular conduction disturbance on electrocardiography, transthoracic echocardiography (TTE) was performed. TTE showed the aortic valve with a hyperechogenic mass and severe aortic regurgitation with a jet directed toward the septum and moderate aortic stenosis. However, a 1.5 x 2.2 cm hyperechogenic mass was noted in the right atrium adjacent to the aortic annulus (Figure 1). Transesophageal echocardiography (TOE) showed a deformed aortic valve with three degenerative leaflets and hyperechogenic mobile vegetations, a circumferential abscess of the aortic annulus with extension of infection toward the right atrium just above the tricuspid septal leaflet and extension of infection toward the left atrium with formation of a fistula detected by color Doppler flow (Figure 2). The patient was treated with vancomycin and benzilpenciline and referred to cardiac surgery, where the aortic valve was replaced with a biological prosthesis and the aortic root was patched. The postoperative course was complicated by the COVID-19 infection. A series of control blood cultures were sterile. After two months of treatment, the patient was discharged home with normal TTE function of the biological aortic valve (Figure 3). Conclusion: TTE and TOE are invaluable for rapid and accurate diagnosis of the anatomic involvement of IE and its extent, leading to appropriate treatment and thus a better prognosis. [ FROM AUTHOR] Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society 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.)

Appendicular peritonitis as a variant of Crohn's disease manifestation in children recovered from a novel coronavirus infection COVID-19.

Immune changes arising against the background of COVID-19 can lead to the manifestation of autoimmune diseases and provoke the development of Crohn's disease. In the presented work, we describe two clinical cases of manifestation of Crohn's disease in children after suffering a novel coronavirus infection COVID-19. Moreover, the variant of manifestation in both cases was spilled purulent appendicular peritonitis. In the first case, the child underwent a traditional appendectomy and abdominal sanitation. However, the choice of traditional appendectomy in this version of the pathological process led to severe consequences for the patient (a complicated postoperative period and multiple surgical interventions), including for the formed intraperitoneal abscesses and intestinal fistula, which is most characteristic of Crohn's disease. Therefore, the patient was diagnosed with Crohn's disease only after numerous operations. Regarding the second case, the situation was completely different, despite the obvious manifestations of ARVI (sore throat, fever), which led to the belated diagnosis of appendicitis in this child. Laparoscopic appendectomy and simultaneous adequate abdominal sanitation made it possible to avoid repeated surgical interventions in this case. In both cases, patients at the diagnosis were sent to federal clinics to select specific therapy. In our opinion, it is worth paying close attention to pediatric patients with a novel coronavirus infection and abdominal pain syndrome since this may be onset of inflammatory bowel disease.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Black pleural effusion caused by a pancreaticopleural fistula secondary to chronic alcoholic pancreatitis exacerbation accompanying COVID-19.

Pancreaticopleural fistula should be considered in alcohol abusers with pleural effusion, which can exhibit a black color.