Evaluation of hydrophilic polymer embolization from endovascular sheath devices in an in vitro perfusion system.

Objective: Case reports, tissue pathology, and autopsies have suggested that the hydrophilic polymer coating designed to improve endovascular deliverability and minimize vessel trauma can embolize and be associated with adverse outcomes such as ischemia, infarction, and death. This study sought to determine whether hydrophilic polymers shed off commercially available sheaths in a controlled in vitro environment, with the hypothesis that significant differences between coated and uncoated (control) sheaths would be found. Methods: Six sheaths from each manufacturer, including Zenith Alpha abdominal endovascular stent grafts (Cook Medical), DrySeal sheaths (W.L. Gore & Associates), and Sentrant Introducer sheaths (Medtronic), were tested in an in vitro environment. Noncoated Check-Flo performer introducer sheaths (Cook Medical) were used as controls. Each test circuit ran for 150 minutes at an output of 3 L/min, the circuit was then drained and the fluid collected. Quantitative analysis included weighing the dried filter paper and using particle size light scattering to quantify the particle size and count. Attenuated total reflectance spectroscopy was also used. Results: Each of the three coated sheaths had significantly greater shedding compared with the control sheaths. The Cook Zenith alpha sheath had significantly more residue weight (2.87 ± 0.52 mg/L) than the Gore DrySeal (1.07 ± 0.06 mg/L) and Medtronic Sentrant introducer (0.98 ± 0.14 mg/L) sheaths. The average particle size was not significantly different between the coated and uncoated (control) sheaths. Attenuated total reflectance spectroscopy identified sheath particulate in the Cook Zenith Alpha and Medtronic Sentrant samples. Conclusions: Polymer embolization was present and significantly greater in all three commercially available hydrophilic sheaths compared with the control group. Further investigation is needed into the clinical significance of these findings.

Investigating the effect of early life antibiotic use on asthma and allergy risk in over 600 000 Canadian children: a protocol for a retrospective cohort study in British Columbia and Manitoba.

INTRODUCTION: Allergic conditions, such as asthma, hay fever and eczema, are some of the most common conditions impacting children globally. There is a strong incentive to study their determinants to improve their prevention. Asthma, hay fever and eczema are influenced through the same immunological pathway and often copresent in children ('the atopic march'). Increasing evidence shows a link between infant antibiotic use and the risk of childhood atopic conditions, mediated through gut microbial dysbiosis during immune system maturation, however, the potential for confounding remains. This study will investigate the relationship between infant antibiotic use and risk of allergic conditions in British Columbian and Manitoban children born over 10 years, adjusting for relevant confounders. METHODS AND ANALYSIS: Provincial administrative datasets will be linked to perform comparable retrospective cohort analyses, using Population Data BC and the Manitoba Population Research Data Repository. All infants born between 2001 and 2011 in BC and Manitoba will be included (approximately 460 000 and 162 500 infants, respectively), following up to age 7. Multivariable logistic regression will determine the outcome risk by the fifth birthday among children who did and did not receive antibiotics before their first birthday. Clinical, demographic and environmental covariates will be explored, and sensitivity analyses performed to reduce confounding by indication. ETHICS AND DISSEMINATION: The University of British Columbia Research Ethics Board (H19-03255) and University of Manitoba Ethics Board (HS25156 (H2021:328)) have approved this study. Data stewardship committees for all administrative datasets have granted permissions, facilitated by Population Data BC and the Manitoba Centre for Health Policy. Permissions from the Canadian Health Infant Longitudinal Development Study are being sought for breastfeeding data (CP185). Findings will be published in scientific journals and presented at infectious disease and respiratory health conferences. A stakeholder committee will guide and enhance sensitive and impactful communication of the findings to new parents.

Penicillin de-labelling in vancouver, British Columbia, Canada: comparison of approaches, outcomes and future directions.

BACKGROUND: Inaccurate penicillin allergy labels lead to inappropriate antibiotic prescriptions and harmful patient consequences. System-wide efforts are needed to remove incorrect penicillin allergy labels, but more health services research is required on how to best deliver these services. METHODS: Data was extracted from five hospitals in Vancouver, British Columbia, Canada from October 2018-May 2022. The primary outcomes of this study were to outline de-labelling protocol designs, identify the roles of various healthcare professionals in de-labelling protocols and identify rates of de-labelling penicillin allergies and associated adverse events at various institutions. Our secondary outcome was to describe de-labelling rates for special populations, including pediatric, obstetric and immunocompromised subpopulations. To achieve these outcomes, participating institutions provided their de-labelling protocol designs and data on program participants. Protocols were then compared to find common themes and differences. Furthermore, adverse events were reviewed and percentages of patients de-labelled at each institution and in total were calculated. RESULTS: Protocols demonstrated a high level of variability, including different methods of participant identification, risk-stratification and roles of providers. All protocols used oral and direct oral challenges, heavily involved pharmacists and had physician oversight. Despite the differences, of the 711 patients enrolled in all programs, 697 (98.0%) were de-labelled. There were 9 adverse events (1.3%) with oral challenges with mainly minor symptoms. CONCLUSIONS: Our data demonstrates that de-labelling programs effectively and safely remove penicillin allergy labels, including pediatric, obstetric and immunocompromised patients. Consistent with current literature, most patients with a penicillin allergy label are not allergic. De-labelling programs could benefit from increasing clinician engagement by increasing accessibility of resources to providers, including guidance for de-labelling of special populations.

Developing International Classification of Disease code definitions for the study of enteric infection sequelae in Canada.

Background: Enteric infections and their chronic sequelae are a major cause of disability and death. Despite the increasing use of administrative health data in measuring the burden of chronic diseases in the population, there is a lack of validated International Classification of Disease (ICD) code-based case definitions, particularly in the Canadian context. Our objective was to validate ICD code definitions for sequelae of enteric infections in Canada: acute kidney injury (AKI); hemolytic uremic syndrome (HUS); thrombotic thrombocytopenic purpura (TTP); Guillain-Barré syndrome/Miller-Fisher syndrome (GBS/MFS); chronic inflammatory demyelinating polyneuropathy (CIDP); ankylosing spondylitis (AS); reactive arthritis; anterior uveitis; Crohn's disease, ulcerative colitis, celiac disease, erythema nodosum (EN); neonatal listeriosis (NL); and Graves' disease (GD). Methods: We used a multi-step approach by conducting a literature review to identify existing validated definitions, a clinician assessment of the validated definitions, a chart review to verify proposed definitions and a final clinician review. We measured the sensitivity and positive predictive value (PPV) of proposed definitions. Results: Forty studies met inclusion criteria. We identified validated definitions for 12 sequelae; clinicians developed three (EN, NL, GD). We reviewed 181 charts for 6 sequelae (AKI, HUS, TTP, GBS/MFS, CIDP, AS). Sensitivity (42.8%-100%) and PPV (63.6%-100%) of ICD code definitions varied. Six definitions were modified by clinicians following the chart review (AKI, TTP, GBS/MFS, CIDP, AS, reactive arthritis) to reflect coding practices, increase specificity or sensitivity, and address logistical constraints. Conclusion: The multi-step design to derive ICD code definitions provided flexibility to identify existing definitions, to improve their sensitivity and PPV and adapt them to the Canadian context.

Child transmission of SARS-CoV-2: a systematic review and meta-analysis.

BACKGROUND: Understanding of the role of children in COVID-19 transmission has significant implications for school and childcare policies, as well as appropriate targeting of vaccine campaigns. The objective of this systematic review was to identify the role of children in SARS-CoV-2 transmission to other children and adults. METHODS: MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Web of Science were electronically searched for articles published before March 31, 2021. Studies of child-to-child and child-to-adult transmission and quantified the incidence of index and resulting secondary attack rates of children and adults in schools, households, and other congregate pediatric settings were identified. All articles describing confirmed transmission of SARS-CoV-2 from a child were included. PRISMA guidelines for data abstraction were followed, with each step conducted by two reviewers. RESULTS: 40 of 6110 articles identified met inclusion criteria. Overall, there were 0.8 secondary cases per primary index case, with a secondary attack rate of 8.4% among known contacts. The secondary attack rate was 26.4% among adult contacts versus 5.7% amongst child contacts. The pooled estimate of a contact of a pediatric index case being infected as secondary case was 0.10 (95% CI 0.03-0.25). CONCLUSIONS: Children transmit COVID-19 at a lower rate to children than to adults. Household adults are at highest risk of transmission from an infected child, more so than adults or children in other settings.

Risk factors for urinary retention after urogynecologic surgery: A retrospective cohort study and prediction model.

AIMS: Postoperative urinary retention (POUR) is a common complication of urogynecological surgery. Our study aimed to identify demographic and perioperative risk factors to construct a prediction model for POUR in urogynecology. METHODS: Our retrospective cohort study reviewed all patients undergoing pelvic reconstructive surgeries at our tertiary care center (Jan 1, 2013-May 1, 2019). Demographic, pre-, intra- and postoperative variables were collected from medical records. The primary outcome, POUR, was defined as (1) early POUR (E-POUR), failing initial trial of void or; (2) late POUR (L-POUR), requiring an indwelling catheter or intermittent catheterization on discharge. Risk factors were identified through univariate and multivariate logistic regression analyses. A clinical prediction model was constructed with the most significant and clinically relevant risk factors. RESULTS: In 501 women, 182 (36.3%) had E-POUR and 61 of these women (12.2% of the entire cohort) had L-POUR. Multivariate logistic regression revealed preoperative postvoid residual (PVR) over 200 ml (odds ratio [OR]: 3.17; p = 0.026), voiding dysfunction symptoms extracted from validated questionnaires (OR: 3.00; p = 0.030), and number of concomitant procedures (OR: 1.30 per procedure; p = 0.021) as significant predictors of E-POUR; preoperative PVR more than 200 ml (OR: 4.07; p = 0.011) and antiincontinence procedure with (OR: 3.34; p = 0.023) and without (OR: 2.64; p = 0.019) concomitant prolapse repair as significant predictors of L-POUR. A prediction model (area under the curve: 0.70) was developed for E-POUR. CONCLUSIONS: Elevated preoperative PVR is the most significant risk factor for POUR. Alongside other risk factors, our prediction model for POUR can be used for patient counseling and surgical planning in urogynecologic surgery.

Massive pulmonary haemorrhage due to severe trauma treated with repeated alveolar lavage combined with extracorporeal membrane oxygenation: A case report.

BACKGROUND: Massive pulmonary haemorrhage can spoil the entire lung and block the airway in a short period of time due to severe bleeding, which quickly leads to death. Alveolar lavage is an effective method for haemostasis and airway maintenance. However, patients often cannot tolerate alveolar lavage due to severe hypoxia. We used extracorporeal membrane oxygenation (ECMO) to overcome this limitation in a patient with massive pulmonary haemorrhage due to severe trauma and succeeded in saving the life by repeated alveolar lavage. CASE SUMMARY: A 22-year-old man sustained multiple injuries in a motor vehicle accident and was transferred to our emergency department. On admission, he had a slight cough and a small amount of bloody sputum; computed tomography revealed multiple fractures and mild pulmonary contusion. At 37 h after admission, he developed severe chest tightness, chest pain, dizziness and haemoptysis. His oxygen saturation was 68%. Emergency endotracheal intubation was performed, and a large amount of bloody sputum was suctioned. After transfer to the intensive care unit, he developed refractory hypoxemia and heparin-free venovenous ECMO was initiated. Fibreoptic bronchoscopy revealed diffuse and profuse blood in all bronchopulmonary segment. Bleeding was observed in the trachea and right bronchus, and repeated alveolar lavage was performed. On day 3, the patient's haemoptysis ceased, and ECMO support was terminated 10 d later. Tracheostomy was performed on day 15, and the patient was weaned from the ventilator on day 21. CONCLUSION: Alveolar lavage combined with ECMO can control bleeding in trauma-induced massive pulmonary haemorrhage, is safe and can be performed bedside.

Association between HLA-DR Expression and Multidrug-resistant Infection in Patients with Severe Acute Pancreatitis.

Multidrug-resistant (MDR) bacterial infection is a common complication of severe acute pancreatitis (SAP). This study aimed to explore the association between human leukocyte antigen-antigen D-related (HLA-DR) expression and multidrug-resistant infection in patients with SAP. A total of 24 SAP patients who were admitted to Nanjing Drum Tower Hospital between May 2015 and December 2016 were enrolled in the study. The percentages of CD4+, CD8+, natural killer (NK), and HLA-DR (CD14+) cells and the CD4+/CD8+ cell ratio on days 1,7,14, and 28 after admission were determined by flow cytometry. Eighteen patients presented with the symptoms of infection. Among them, 55.6% patients (10/18) developed MDR infection. The most common causative MDR organisms were Enterobacter cloacae and Acinetobacter baumannii. The CD4+/CD8+ cell ratio and the percentage of NK cells were similar between patients with non-MDR and patients with MDR infections. In patients without infection, the HLA-DR percentage was maintained at a high level throughout the 28 days. Compared to the patients without any infection, the HLA-DR percentage in patients with non-MDR infection was reduced on day 1 but increased and reached similar levels on day 28. In patients with MDR infection, the HLA-DR percentage remained below normal levels at all-time points. It was concluded that persistent down-regulation of HLA-DR expression is associated with MDR bacterial infection in patients with SAP.

[Mean arterial pressure as an indicator of fluid responsiveness in patients with septic shock].

OBJECTIVE: To assess the value of mean arterial pressure (MAP) as an indicator for fluid responsiveness in patients with septic shock. METHODS: A retrospective analysis of clinical data of 68 patients with septic shock receiving volume resuscitation in intensive care unit (ICU) of Drum-tower Hospital Affiliated to Medical School of Nanjing University from June 2011 to February 2012 was conducted. The changes in heart rate (HR), MAP, systolic arterial pressure (SBP), diastolic arterial pressure (DBP), pluse pressure (PP), central venous pressure (CVP) were recorded before and after volume resuscitations. Cardiac index (CI), intrathoracic blood volume index (ITBVI), systemic vessel resistance index (SVRI) and extravascular lung water index (EVLWI) were evaluated by using the thermodilution technique of pulse induced continuous cardiac output (PiCCO). All the patients were divided into two groups, responded group (ΔCI%≥10%) and the unresponded group (ΔCI%<10%), according to the change in CI (ΔCI%). Then the patients were divided into two subgroups, namely low MAP group(LMAP, MAP≤65 mm Hg) and high MAP group(HMAP, MAP>65 mm Hg), according to the initial value of MAP. Then compared the changes in hemodynamic variables before and after volume resuscitation in each subgroup and assess the correlation between the changes in MAP (ΔMAP%) and ΔCI%. RESULTS: Forty-four (64.7%) patients responded to the fluid challenge according to the predetermined criteria, SBP, DBP, MAP, PP, CI, CVP, ITBVI were increased significantly (SBP: 126.5±23.8 mm Hg vs. 110.7±20.2 mm Hg, DBP: 58.1±14.8 mm Hg vs. 52.8±13.5 mm Hg, MAP: 80.3±19.2 mm Hg vs. 70.1±15.8 mm Hg, PP: 68.2±18.7 mm Hg vs. 58.0±15.8 mm Hg, CI: 70.0±21.7 ml×s(-1)×m(-2) vs. 53.3±20.0 ml×s(-1)×m(-2), CVP: 13.0±4.5 mm Hg vs. 10.2±4.4 mm Hg, ITBVI: 909.1±248.7 ml/m(2) vs. 773.5±220.7 ml/m(2), all P<0.01), and SVRI was decreased significantly (130.9±47.7 kPa×s×L(-1)×m(-2) vs. 157.1±59.1 kPa×s×L(-1)×m(-2), P<0.01). HR and EVLWI did not change significantly. There was no significant correlation between ΔMAP% and ΔCI% in all the patients (r=0.266,P=0.054). In the sub-group of LMAP (n=39), ΔMAP% was positively correlated with ΔCI% (r=0.473, P=0.03), the under the receiver operating characteristic curve (ROC curve, AUC) was 0.763, 95% confidence interval (95%CI) 0.554 - 0.973, P=0.231. However, there was no significant correlation between the ΔMAP% and ΔCI% (r=-0.088, P=0.633) in the sub-group of HMAP (n=29). CONCLUSION: MAP can be used as an indicator of fluid responsiveness when the initial value of MAP was at a relative low level (MAP≤65 mm Hg) in patients with septic shock.