455 A Case of An Unusual Penetrating Brain Injury

Introduction

Penetrating brain injuries (PBI) are less common than closed head traumas. Interest in frontal lobe injuries dates back to 1848’s famous Phineas Gage incident. Here, we report a case of a construction worker, who showed a remarkable neuropsychiatric outcome following a workplace accident.

Case Presentation

45year old gentleman came with complaint of a foreign body accidentally lodged in his forehead. He had no neurological deficits or CSF leak. X-ray revealed that a 5.5cm metallic screw was penetrating his skull, headfirst; CT revealed that approximately 3cm of the screw was in the frontal sinus. He was given antiepileptics and antibiotics prophylactically. Surgically the screw was removed by raising a bone flap and mobilizing the screw carefully by cutting the dura and adequate irrigation, causing minimal damage to the brain parenchyma. The dural deficits were repaired and the frontal sinus was canalized, then a drain was placed, and the patient was shifted to ICU for postoperative monitoring.

Discussion

It is important to prognosticate PBI as they can have neurological deficits that may be lifelong. Understanding the mechanism of injury, aggressive medical management and immediate surgical intervention may lead to improved outcomes. A foreign object of the size of 5.5cm, completely penetrating the skull would have otherwise resulted in extensive parenchymal damage. Literature suggests that no two people have an identical frontal sinus. In our patient the size the frontal sinus has served the purpose of protection against PBI and has resulted in minimal parenchymal injury (of only about 1cm).

Catheter-related infection rates in patients receiving customized home parenteral nutrition compared with multichamber bags

BACKGROUND

The risk of bloodstream infections may be increased in hospitalized patients receiving ready-made parenteral nutrition (PN) multichamber bags (MCBs) compared with customized PN; however, as highlighted in recent international guidelines, there are no comparable data relating to home PN (HPN).

METHODS

Data from a prospectively maintained database were analyzed to compare incidence rates of catheter-related bloodstream infections (CRBSIs) between patients receiving customized HPN compared with MCB HPN at a national UK referral center between May 2018 and August 2020.

RESULTS

Sixty patients with chronic intestinal failure were commenced on MCBs and 45 received customized HPN for a total of 5914 and 7641 catheter days, respectively. No difference in CRBSI incidence was found (0.51/1000 catheter days for MCBs, 0.39/1000 catheter days for customized HPN; incidence rate ratio, 1.29; 95% CI, 0.26-6.37). Eighteen patients were switched from customized HPN to MCB HPN. The study period covered 7401 catheter days receiving customized HPN and 4834 days on MCBs. No significant change was noted in the CRBSI rates following this switch (0.27/1000 catheter days receiving customized HPN vs 0.21/1000 catheter days on MCBs; incidence rate ratio, 1.31; 95% CI, 0.12-14.3).

CONCLUSION

The use of MCBs for HPN patients is not associated with an increased risk of CRBSI. This study will inform international guidelines and provide reassurance for the continued, safe use of MCB HPN.

Provision of a local anaesthetic minor procedures service by surgical advanced clinical practitioners: 5-year study

BACKGROUND

Surgical advanced clinical practitioners (SACPs) form part of the extended surgical workforce drawn from a variety of allied healthcare backgrounds. The primary aim of this study was to determine whether there was a financial benefit in having minor surgical procedures undertaken by dedicated SACPs compared with operating lists assigned to consultant surgeons.

METHODS

This was a retrospective cohort study including all patients who had minor 'lumps and bumps' procedures undertaken between April 2014 and August 2019 at East Lancashire Hospitals NHS Trust under local anaesthetic by the general surgery team. Clinical patient information, including lesion type, was collected along with operating room staffing levels and duration of operation. The cost of the procedure was calculated as operating time multiplied by cost of staff per minute according to local banding.

RESULTS

A total of 1399 patients had a lesion excised; 907 procedures were carried out by a doctor, and the rest independently by a SACP. The majority of lesions excised were lipomas and cysts. There was no difference in the median surgical time taken between SACPs and doctors (20 (i.q.r. 14-28) min). Minor procedures carried out on consultant surgeon lists cost 62.3 per cent (€25.33) more on average than those on SACP lists (median €65.96 versus 40.63 respectively; P < 0.001).

CONCLUSION

A dedicated and independent SACP 'lumps and bumps' list was financially beneficial. Operating times were similar to those of doctors. These lists safely free trainee and consultant surgeons to undertake more complex work.

Limited utility of plasma elafin as a biomarker for skin graft-versus-host disease following allogeneic stem cell transplantation

BACKGROUND

Acute cutaneous graft-versus-host disease (acGVHD) following haematopoietic stem cell transplant (HSCT) is common but difficult to distinguish from other causes of rash. Plasma elafin has been proposed as a diagnostic and prognostic biomarker of skin GVHD.

AIM

To evaluate the role of plasma elafin as a biomarker in acGVHD in an Indian population.

METHODS

Plasma elafin was evaluated in a prospective study of HSCT recipients, conducted over 2 years, taking measurements at baseline and at onset of skin rash after HSCT. Patients were categorized into those with GVHD rash, those with non-GVHD rash and those with no rash and the three groups were compared.

RESULTS

Two hundred and sixty-one patients with a median age of 16 years (range 1-61 years) and a male predominance (175 : 86 M/F) underwent HSCT during the study period: 56 patients in the GVHD group, 49 in the non-GVHD group and 156 in the no-rash group. The median baseline elafin was similar in all three groups. At the onset of rash, median elafin level was similar between GVHD and non-GVHD rash (34 549 vs. 32 077 pg/mL; P = 0.58) and between GVHD and no rash (34 549 vs. 26 197 pg/mL; P = 0.08). A rise in elafin from baseline was significantly different between GVHD and no rash (P < 0.001) but not between GVHD and non-GVHD rash (P = 0.44).

CONCLUSION

The utility of plasma elafin as a biomarker of skin GVHD is very limited. Plasma elafin, although elevated in cutaneous GVHD, is not helpful in distinguishing between GVHD rash and other causes of rash following HSCT.

Examining antidepressant use in palliative care patients by risk of antidepressant discontinuation syndrome

Antidepressant drugs, which are widely used in palliative care patients for both management of psychiatric disorders and non-psychiatric symptoms, may cause a cluster of distressing symptoms on discontinuation. In dying patients, cessation of oral intake may occur either temporarily or permanently for reasons related to disease or its treatment, as well as in the days before death. We examined antidepressant use in palliative care patients by risk of antidepressant discontinuation syndrome (ADDS). Strategies for reducing the risk of ADDS, and for managing it that should occur, are discussed.

Perinatal loss and parental loneliness: Narratives of late termination of pregnancy

Advances in perinatal medicine, present increasing numbers of women with difficult decisions about their pregnancy. We explored the views of 5 parents and 5 perinatal healthcare professionals regarding late termination of pregnancy following the principles of qualitative content analysis. Parents deciding on whether to (dis)continue pregnancy needed more time and decisional support. Decentralized care and lacking continuity between caregivers led to negative experiences. No standardized bereavement services were offered after leaving the hospital. Integrating principles of perinatal palliative care to care might help to offer further decisional support and to overcome the fragmentation of care.

Factors affecting antidepressant use by patients requiring home parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) is a life-saving therapy for patients with chronic intestinal failure but can be associated with a degree of psychological distress. The factors associated with the need for antidepressants (ADs) in this cohort have not yet been described.

METHODS

The study involved prospective data collection from patients attending an HPN clinic at a national intestinal failure referral center. Patients requiring HPN as a result of active malignancy were excluded. Patients were divided in 2 groups according to AD usage; demographic, anthropometric, socioeconomic characteristics, and intravenous supplementation (IVS) regimens were compared between groups.

RESULTS

A total of 184 patients were recruited between July 2018 and April 2019, with an overall prevalence of AD use of 41.7% (70/168 patients). Daily mean IVS volume was significantly higher among patients taking AD ("AD" group; 2125.48 ± 991.8 ml/day, "no-AD" group; 1828.54 ± 847.0 ml/day, P = .039), with the proportion of patients needing high-volume IVS (≥3000 ml/day) being 3 times higher in the AD group (20.0%(14/70 patients) vs 6.1% (6/98 patients), P = .006). The average energy IVS infusion per day was similar between the groups.

CONCLUSION

This is the first study to demonstrate that AD use correlates with higher IVS volume rather than energy requirements in HPN patients, suggesting that high IVS volume requirements may be better associated with the patient's disease burden. Early and tailored mental health intervention may be beneficial in those with high IVS volume requirements.

The accuracy of pre-operative (P)-POSSUM scoring and cardiopulmonary exercise testing in predicting morbidity and mortality after pancreatic and liver surgery: A systematic review

Background

Cardiopulmonary exercise-testing (CPET) and the (Portsmouth) Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity ((P)-POSSUM) are used as pre-operative risk stratification and audit tools in general surgery, however, both have been demonstrated to have limitations in major hepatopancreatobiliary (HPB) surgery.

Materials and methods

The aim of this review is to determine if CPET and (P)-POSSUM scoring systems accurately predict morbidity and mortality. Eligible articles were identified with an electronic database search. Analysis according to surgery type and tool used was performed.

Results

Twenty-five studies were included in the final review. POSSUM predicted morbidity demonstrated weighted O/E ratios of 0.75(95%CI0.57–0.97) in hepatic surgery and 0.85(95%CI0.8–0.9) in pancreatic surgery. P-POSSUM predicted mortality in pancreatic surgery demonstrated an O/E ratio of 0.75(95%CI0.27–2.13) and 0.94(95%CI0.57–1.55) in hepatic surgery. In both pancreatic and hepatic surgery an anaerobic threshold(AT) of between 9 0.5–11.5 ml/kg/min was predictive of post-operative complications, and in pancreatic surgery ventilatory equivalence of carbon dioxide(˙VE/˙VCO2) was predictive of 30-day mortality.

Conclusion

POSSUM demonstrates an overall lack of predictive fit for morbidity, whilst CPET variables provide some predictive power for post-operative outcomes. Development of a new HPB specific risk prediction tool would be beneficial; the combination of parameters from POSSUM and CPET, alongside HPB specific markers could overcome current limitations.

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Current pre-operative scoring for pancreatic and liver surgery is inaccurate.

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In pancreatic and liver surgery anaerobic threshold scores were predictive of complications.

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In pancreatic surgery ventilatory equivalence of carbon dioxide was predictive of mortality.

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P-POSSUM is inaccurate for predicting mortality and morbidity in pancreatic surgery.

Intraductal Papillary Adenocarcinoma Of The Bile Duct With Associated Invasive Neuroendocrine Component: Case Report

Casestudy

Intraductal papillary neoplasm of the bile duct (IPNB) is a variant of bile duct carcinoma that is characterized by intraductal growth and better outcomes compared with common cholangiocarcinoma. IPNBs are mainly found in patients from Far Eastern countries, where hepatolithiasis and clonorchiasis are endemic.

Approximately 40%-80% of IPNBs are associated with invasive carcinoma. The invasive carcinomas are most often tubular or mucinous type. Invasive neuroendocrine component has not been previously described.

We present a case of 69 year-old African American male who presented with worsening abdominal pain and jaundice over few months. Computed tomography showed 4 cm mass near the porta hepatis with massive ductal dilatation. A fine needle aspiration of the mass was performed and a diagnosis of adenocarcinoma was made. Subsequently, the patient underwent Right Trisegmentectomy.

Conclusion

Histologic sections revealed intraductal papillary neoplasm in the bile duct lumina. The papillae were lined by columnar epithelial cells with delicate fibrovascular cores. The tumor cell nuclei were slightly elongated, hyperchromatic and basally located without significant multilayering. The cytoplasm was eosinophilic with occasional intestinal differentiation. Frank invasion of the stalk and underlying periductular tissues was identified. Interestingly; the invasive component had different cytological features than the intraductal component, it was composed of small to medium sized cells with granular cytoplasm. The nuclei were uniform and round with “salt and pepper” chromatin. The invasive component stained positively for the neuroendocrine markers (Synaptophysin, Chromogranin and CD56), whereas the intraductal component stained positively for CK7, CK20 and CDX2 and negative for neuroendocrine markers.

Three years later, a recurrent tumor was found in the left lobe on imaging. Biopsy of the lesion showed metastatic neuroendocrine carcinoma. The intraductal papillary neoplasm with invasive neuroendocrine component is very unusual tumor, we think more studies are warranted to best evaluate the treatment options and the prognosis of such neoplasms.

Characterization of a novel enzyme from Photobacterium phosphoreum with histidine decarboxylase activity

Histamine or scombrotoxin fish poisoning is caused by ingestion of bacterially produced histamine in fish. Histamine-producing bacteria generally contain the histidine decarboxylase gene (hdc). However, some strains of Photobacterium phosphoreum are known to produce significant levels of histamine, although the hdc gene in these strains has not been recognized. The objective of this study was to investigate a previously unidentified mechanism of histamine production by P. phosphoreum. We identified a protein with histidine decarboxylase (HDC) activity comparable to activity of the pyridoxal-5-phosphate (PLP) dependent HDC from P. kishitanii and M. morganii. The newly identified protein (HDC2) in P. phosphoreum and P. kishitanii strains, was approximately 2× longer than the HDC protein from other Gram-negative bacteria and had 12% similarity to previously identified HDCs. In addition, the hdc2 gene cluster in P. phosphoreum was identical to the hdc gene cluster in P. kishitanii. HDC2 had optimal activity at 20-35 °C, at pH 4, and was not affected by 0-8% NaCl concentrations. Compared to the hdc gene from P. kishitanii, expression of the hdc2 gene was constitutive and not affected by pH or excess histidine. This newly identified protein explains possible mechanisms of histamine production in P. phosphoreum. Characterization of this protein will help in designing control measures to prevent or reduce histamine production in fish.

Infective Endocarditis in Patients With Intestinal Failure: Experience From a National Referral Center

BACKGROUND

Infective endocarditis (IE) is a recognized complication of central line-associated bloodstream infection (CLABSI). Central venous access devices (CVADs) are essential for the delivery of long-term parenteral nutrition (PN), yet there are no published data as to the prevalence, characteristics and outcomes of IE in this population.

METHODS

A prospectively maintained database of patients with intestinal failure (IF) types 2 and 3, managed by a national intestinal failure center between January 2010 and December 2018, was analyzed retrospectively and relevant factors extracted from case records.

RESULTS

A total of 745 patients with IF and CVADs in situ on admission, or placed during their stay, were admitted over the duration of this study, 640 with type 2 IF and 105 with type 3 IF. Two hundred eighty-two echocardiograms were performed to investigate potential IE associated with a CLABSI event. Four cases of IE were identified in the entire cohort of 782,666 catheter days (IE incidence rate: 0.005 per 1000 catheter days and 187 per 100,000 person-years for the entire cohort; 0.048 per 1000 inpatient catheter days for acute type 2 IF, 0.0026 per 1000 outpatient catheter days [ie, 99 per 100,000 person-years for outpatients with type 3 IF]).

CONCLUSION

IE is rare in the type 3 IF population and a rare consequence of CLABSI in inpatient acute type 2 IF. However, mortality and morbidity are high. Routine echocardiography may not be warranted for investigation of CLABSI unless there is a high risk of IE or a virulent organism is involved.

Causes and Prognosis of Intestinal Failure in Crohn's Disease: An 18-year Experience From a National Centre

BACKGROUND AND AIMS

Intestinal failure [IF] is a feared complication of Crohn's disease [CD]. Although cumulative loss of small bowel due to bowel resections is thought to be the dominant cause, the causes and outcomes have not been reported.

METHODS

Consecutive adult patients referred to a national intestinal failure unit over 2000-2018 with a diagnosis of CD, and subsequently treated with parenteral nutrition during at least 12 months, were included in this longitudinal cohort study. Data were extracted from a prospective institutional clinical database and patient records.

RESULTS

A total of 121 patients were included. Of these, 62 [51%] of patients developed IF as a consequence of abdominal sepsis complicating abdominal surgery; small bowel resection, primary disease activity, and proximal stoma were less common causes [31%, 12%, and 6%, respectively]. Further, 32 had perianastomotic sepsis, and 15 of those had documented risk factors for anastomotic dehiscence. On Kaplan-Meier analysis, 40% of all patients regained nutritional autonomy within 10 years and none did subsequently; 14% of patients developed intestinal failure-associated liver disease. On Kaplan-Meier analysis, projected mean age of death was 74 years.2.

CONCLUSIONS

IF is a severe complication of CD, with 60% of patients permanently dependent on parenteral nutrition. The most frequent event leading directly to IF was a septic complication following abdominal surgery, in many cases following intestinal anastomosis in the presence of significant risk factors for anastomotic dehiscence. A reduced need for abdominal surgery, an increased awareness of perioperative risk factors, and structured pre-operative optimisation may reduce the incidence of IF in CD.