Improving the quality of discharge care plan in the heart failure with reduced ejection fraction (HFrEF) cohort: a quality improvement study

Background

High-quality heart failure (HF) discharge summary (DS) is the cornerstone of effective communication during the transition from specialists to primary care. The combination of continuing involvement of multidisciplinary members, varying individual tolerance to treatments, and the need for multiple investigations beget intricate HFrEF management. The quality of the information included in DS following HF-related hospitalisation varies widely and may be sub-optimal in communicating patient's in-hospital care, leading to inadequate compliance to guideline-directed medical therapy (GDMT) and increased risk of re-hospitalisation. Notwithstanding this real-world observation, there remains a paucity of consensus on the standard of measurements of HF DS.

Purpose

We aimed to optimise the transmission of information between patients and HF multidisciplinary members to improve adherence to GDMT, follow-up (F/U) care coordination and patient education in line with the National Institute for Health and Care Excellence (NICE) and the European Society of Cardiology (ESC) recommendations.

Methods

A random sampling of the HFrEF cohort discharged from the cardiac unit at our institution following HF-related hospitalisation was performed across four distinct time points matched with respective interventions. Three iterative cycles (baseline analysis and two educational interventions – departmental teaching and dissemination of innovative mnemonics sheets – THE WET TO DRY [Figure 1]) were completed using Plan-Do-Study-Act (PDSA) methodology. The quality of patients DS was objectively analysed based on the inclusion of physiological and investigation parameters, in-patient treatment, initiation/titration of GDMT, F/U care coordination, and patient education.

Results

Sixty-six patients, mean±SD age 74.6±12.8y were enrolled between 2018–2021. The baseline reporting of presenting complaints, trigger and investigation findings were high and consistent throughout all cycles. A positive trend was observed in the reporting of physiological parameters and in-patient treatment post-interventions. Patient education and vaccines offered remained low despite improving compliance. As such, a consensus on the provision of nurse-led pre-discharge review label and interactive patient personal passport (Figure 1) was achieved via a group of cardiologists and HF specialist nurses to address identified practice gap from preceding PDSA cycles. Full adherence to GDMT and the inclusion of F/U pathway were observed following the provision of nurse-led review label (Figure 2).

Conclusion

This study demonstrates that educational interventions – departmental teaching and innovative mnemonics can be effective in improving the quality of HF DS. Structured nurse-led review label and interactive patient personal passport are feasible interventions, which can be implemented at minimal cost to sustain adherence to GDMT, F/U care coordination and individualised patient education.

Funding Acknowledgement

Type of funding sources: None.

P–136 Factors predicting clinical outcomes of 511 recipients of vitrified oocyte donation from an UK-regulated egg bank

Study question

Do established donor and recipient clinical markers predict recipient clinical pregnancy and live birth rates (LBRs) in a vitrified oocyte donation programme?

Summary answer

Recipient BMI and previous miscarriages predicted cumulative LBR. Likelihood of clinical pregnancy and LBR was higher in recipients of donors aged 23–29 than donors 18–22.

What is known already

The influence of age on ovarian reserve underlies the upper limit of 35 years for UK donors. However, recent evidence suggests that oocyte aneuploidy rates follow an inverse U-shaped curve in relation to a woman’s age. Conflicting evidence exists regarding the impact of other donor-related factors including BMI, AMH, oocyte yield and prior reproductive history on recipient outcomes. Moreover, the effect of recipient age, BMI, and reproductive history on oocyte donation outcome remains unclear.

Study design, size, duration

Retrospective cohort study of 325 altruistic oocyte donors matched to a total of 511 recipients. Only first donations taking place between January 2017 and December 2019 were included.

Participants/materials, setting, methods

All oocyte donors were altruistic volunteers aged 18–35 with no prior infertility diagnosis. Donor and recipient screening for suitability and safety was carried out according to the Human Fertilisation Embryology Authority guidelines. Backward stepwise logistic regression was used to identify donor, recipient and embryology parameters predictive of recipient primary outcomes defined as clinical pregnancy and live birth, either cumulative or after the first embryo transfer (ET).

Main results and the role of chance

A total of 705 fresh and frozen/thawed ETs were performed, of which 76% were elective single embryo transfers (eSETs) of blastocysts (96.5%), resulting in a cumulative clinical pregnancy and LBR of 83.5% and 70.5% respectively after 3 ETs. Recipient BMI and previous miscarriages were predictors of cumulative LBR (p < 0.05). The ratio of transferrable embryos per oocytes received/fertilised and the number of ETs needed to achieve the intended primary outcome were predictors of cumulative clinical pregnancy and LBR (p < 0.05). Donor age 18–22 was associated with lower incidence of recipient clinical pregnancy and live birth after the first ET, as compared to donor age 23–29 (p < 0.05).

Limitations, reasons for caution

The present study included only healthy oocyte donors, thus conclusions may not apply to subfertile or less healthy women. Male factors were not accounted for.

Wider implications of the findings: We demonstrate the efficacy of vitrified oocyte donation treatment and identify recipient BMI, previous miscarriages and embryology parameters as predictors of cumulative LBR. Additionally, the choice of donors aged 18–22 instead of older donors is found not to be advantageous for increasing the chance of clinical pregnancy and live birth.

Trial registration number

Not applicable

Zika virus oncolytic activity requires CD8+ T cells and is boosted by immune checkpoint blockade

Glioblastoma multiforme (GBM) is a fatal human cancer in part because GBM stem cells are resistant to therapy and recurrence is inevitable. Previously, we demonstrated Zika virus (ZIKV) targets GBM stem cells and prevents death of mice with gliomas. Here, we evaluated the immunological basis of ZIKV-mediated protection against GBM. Introduction of ZIKV into the brain tumor increased recruitment of CD8⁺ T and myeloid cells to the tumor microenvironment. CD8⁺ T cells were required for ZIKV-dependent tumor clearance because survival benefits were lost with CD8⁺ T cell depletion. Moreover, while anti–PD-1 antibody monotherapy moderately improved tumor survival, when coadministered with ZIKV, survival increased. ZIKV-mediated tumor clearance also resulted in durable protection against syngeneic tumor rechallenge, which also depended on CD8⁺ T cells. To address safety concerns, we generated an immune-sensitized ZIKV strain, which was effective alone or in combination with immunotherapy. Thus, oncolytic ZIKV treatment can be leveraged by immunotherapies, which may prompt combination treatment paradigms for adult patients with GBM.

A single-centre experience and literature review of Flow Re-Directional Endoluminal Device (FRED) in endovascular treatment of intracranial aneurysms

AIM

To present initial single-centre experience with the Flow Re-Direction Endoluminal Device, FRED.

MATERIALS AND METHODS

This was a retrospective study. All patients treated with FRED from October 2015 to April 2017 were included in the study. Details of the aneurysms, complications as well as follow-up results were recorded. A PubMed search was performed using the keywords "Flow Re-Direction Endoluminal Device", "FRED", "flow diverter", "FD", "FD Stent", "flow re-direction" and "flow redirection" and the results were reviewed and compared to the present authors.

RESULTS

A total of 21 patients with 25 aneurysms were analysed. No patient was lost to follow-up. At 6 months follow-up, 17 aneurysms (68%) were completely occluded, five had reduced flow, two had persistent flow and the remaining one showed increased flow. Two aneurysms from the reduced flow at 6 months had achieved complete occlusion at 1 year, raising the complete occlusion rate to 76%. Overall, 22/25 (88%) aneurysms were either occluded completely or had reduced flow at 1 year. The appearances of the other aneurysms were stable in subsequent follow-ups. Three complications were recorded (one haemorrhagic, two occlusive/thromboembolic). There was no mortality in the present study. The occlusion rate at University Hospital of Wales as well as the complication rate was comparable to other centres on published data.

CONCLUSION

FRED is a safe and effective flow diverter, which can be used to treat complex aneurysms that would have been of higher risk and for which for conventional coiling would be ineffective or unsuitable.

IMMU-43. ZIKA VIRUS TO TREAT GLIOMA: TURNING COLD TUMORS HOT

GBM is a hallmark example of an immunotherapy-resistant tumor. Previously, we discovered that Zika virus (ZIKV) has a natural honing capacity to specifically kill GBM stem cells (GSCs). Using two syngeneic glioma models, GL261 and CT2A, we found that in vivo intratumoral ZIKV treatment reduces tumor size and extends median survival far beyond that expected for its anti-GSC effects; additionally, approximately 50% of mice were long-term survivors. We now report that ZIKV treatment is associated with an increase in tumor-specific CD8+ T cells and activated myeloid cells expressing MHC-II and NOS2. Treatment with CD8-depleting antibody abrogates the survival advantage conferred by ZIKV, demonstrating that CD8+ T cells are required for ZIKV efficacy. Remarkably, ZIKV treatment also confers protection against tumor re-challenge 1.5 years after the original treatment, and this too is dependent on CD8+ T cells. Lastly, in a bilateral tumor implantation model, intratumoral ZIKV treatment of one tumor increases overall survival, suggesting ZIKV is efficacious because it generates a global anti-tumor response. Building on the observation that ZIKV treatment increases CD8+ T cells in the tumor bed, we combined ZIKV with α-PD1 immunotherapy. We found survival was dramatically increased compared to either treatment alone. Finally, to improve safety of potential ZIKV treatment for patients, we generated an immune-sensitized virus. This strain remains efficacious as a single agent and in combination with immunotherapy in vivo. Overall, our results suggest ZIKV treatment addresses two key problems in our current treatment of GBM: it specifically targets highly resistant GSC and initiates a potent anti-tumor immune response against the remaining tumor. Our work reveals the mechanistic basis of ZIKV efficacy and demonstrates the potential for ZIKV as a therapy for GBM.

SARS-CoV-2 infection of human ACE2-transgenic mice causes severe lung inflammation and impaired function

Although animal models have been evaluated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, none have fully recapitulated the lung disease phenotypes seen in humans who have been hospitalized. Here, we evaluate transgenic mice expressing the human angiotensin I-converting enzyme 2 (ACE2) receptor driven by the cytokeratin-18 (K18) gene promoter (K18-hACE2) as a model of SARS-CoV-2 infection. Intranasal inoculation of SARS-CoV-2 in K18-hACE2 mice results in high levels of viral infection in lungs, with spread to other organs. A decline in pulmonary function occurs 4 days after peak viral titer and correlates with infiltration of monocytes, neutrophils and activated T cells. SARS-CoV-2-infected lung tissues show a massively upregulated innate immune response with signatures of nuclear factor-κB-dependent, type I and II interferon signaling, and leukocyte activation pathways. Thus, the K18-hACE2 model of SARS-CoV-2 infection shares many features of severe COVID-19 infection and can be used to define the basis of lung disease and test immune and antiviral-based countermeasures.

Regional Mechanical Thrombectomy Imaging Protocol in Patients Presenting with Acute Ischemic Stroke during the COVID-19 Pandemic

BACKGROUND AND PURPOSE

Chest CT is a rapid, useful additional screening tool for coronavirus disease 2019 (COVID-19) in emergent procedures. We describe the feasibility and interim outcome of implementing a modified imaging algorithm for COVID-19 risk stratification across a regional network of primary stroke centers in the work-up of acute ischemic stroke referrals for time-critical mechanical thrombectomy.

MATERIALS AND METHODS

We undertook a retrospective review of 49 patients referred to the regional neuroscience unit for consideration of mechanical thrombectomy between April 14, 2020, and May 21, 2020. During this time, all referring units followed a standard imaging protocol that included a chest CT in addition to a head CT and CT angiogram to identify Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infective pulmonary changes.

RESULTS

Overall, 2 patients had typical COVID-19 radiologic features and tested positive, while 7 patients had indeterminate imaging findings and tested negative. The others had normal or atypical changes and were not diagnosed with or suspected of having COVID-19. There was an overall sensitivity of 100%, specificity of 74.1%, negative predictive value of 100%, and positive predictive value of 22.2% when using chest CT to diagnose COVID-19 in comparison with the real-time reverse transcriptase-polymerase chain reaction test. The mean additional time and radiation dose incurred for the chest CT were 184 ± 65.5 seconds and 2.47 ± 1.03 mSv. Multiple cardiovascular and pulmonary incidental findings of clinical relevance were identified in our patient population.

CONCLUSIONS

Chest CT provides a pragmatic, rapid additional tool for COVID-19 risk stratification among patients referred for mechanical thrombectomy. Its inclusion in a standardized regional stroke imaging protocol has enabled efficient use of hospital resources with minimal compromise or delay to the overall patient treatment schedule.

Correction to: Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries

[This corrects the article DOI: 10.1186/s41016-020-00194-1.].

SARS-CoV-2 infection in the lungs of human ACE2 transgenic mice causes severe inflammation, immune cell infiltration, and compromised respiratory function

Severe Acute Respiratory Syndrome Coronavirus -2 (SARS-CoV-2) emerged in late 2019 and has spread worldwide resulting in the Coronavirus Disease 2019 (COVID-19) pandemic. Although animal models have been evaluated for SARS-CoV-2 infection, none have recapitulated the severe lung disease phenotypes seen in hospitalized human cases. Here, we evaluate heterozygous transgenic mice expressing the human ACE2 receptor driven by the epithelial cell cytokeratin-18 gene promoter (K18-hACE2) as a model of SARS-CoV-2 infection. Intranasal inoculation of SARS-CoV-2 in K18-hACE2 mice results in high levels of viral infection in lung tissues with additional spread to other organs. Remarkably, a decline in pulmonary function, as measured by static and dynamic tests of respiratory capacity, occurs 4 days after peak viral titer and correlates with an inflammatory response marked by infiltration into the lung of monocytes, neutrophils, and activated T cells resulting in pneumonia. Cytokine profiling and RNA sequencing analysis of SARS-CoV-2-infected lung tissues show a massively upregulated innate immune response with prominent signatures of NF-kB-dependent, type I and II interferon signaling, and leukocyte activation pathways. Thus, the K18-hACE2 model of SARS-CoV-2 infection recapitulates many features of severe COVID-19 infection in humans and can be used to define the mechanistic basis of lung disease and test immune and antiviral-based countermeasures.

Dexmedetomidine infusion for sedation in a patient with myotonic dystrophy

Myotonic dystrophy type 1 is the most common muscular dystrophy in adults. Anaesthetic management should take into consideration the numerous body systems affected, including the musculoskeletal; respiratory; cardiovascular; gastro-intestinal; and central nervous systems. A 42-year-old man with myotonic dystrophy presented for septoplasty and bilateral inferior turbinate reductions. He had severe upper and lower extremity myotonia and weakness, pulmonary impairment with non-obstructive patterns and first-degree atrioventricular block with reduced ejection fraction. He used bilevel positive airway pressure, a cough assist device and was paced 3% of the time with a single-chamber pacemaker. To reduce potential complications associated with opioid use and general anaesthetics, an opioid-free technique was planned using local anaesthetic infiltration and sedation with a dexmedetomidine infusion. The patient maintained spontaneous ventilation and haemodynamic stability, and had an uneventful postoperative course. Dexmedetomidine is a highly selective α2-adrenergic receptor agonist that has the ability to provide sedation, analgesia and anxiolysis with a stable haemodynamic profile. Avoiding both opioids and general anaesthetics in these patients may decrease the risk of peri-operative complications.

Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries

Globally, the discipline of neurosurgery has evolved remarkably fast. Despite being one of the latest medical specialties, which appeared only around hundred years ago, it has witnessed innovations in the aspects of diagnostics methods, macro and micro surgical techniques, and treatment modalities. Unfortunately, this development is not evenly distributed between developed and developing countries. The same is the case with neurosurgical education and training, which developed from only traditional apprentice programs in the past to more structured, competence-based programs with various teaching methods being utilized, in recent times. A similar gap can be observed between developed and developing counties when it comes to neurosurgical education. Fortunately, most of the scholars working in this field do understand the coherent relationship between neurosurgical education and neurosurgical practice. In context to this understanding, a symposium was organized during the World Federation of Neurological Surgeons (WFNS) Special World Congress Beijing 2019. This symposium was the brain child of Prof. Yoko Kato—one of the eminent leaders in neurosurgery and an inspiration for female neurosurgeons. Invited speakers from different continents presented the stages of development of neurosurgical education in their respective countries. This paper summarizes the outcome of these presentations, with particular emphasis on and the challenges faced by developing countries in terms of neurosurgical education and strategies to cope with these challenges.

Propensity score matching/reweighting analysis comparing intravenous golimumab to infliximab for ankylosing spondylitis using data from the GO-ALIVE and ASSERT trials

Objective

To compare the relative efficacy of intravenous golimumab (GOL IV) and infliximab (IFX) for active ankylosing spondylitis (AS).

Methods

Propensity score (PS) methods were used to compare the efficacy of GOL IV 2 mg/kg and IFX 5 mg/kg using individual patient data (IPD) from the active arms of the phase 3 GO-ALIVE and ASSERT studies. Outcomes included the proportion of patients with a ≥ 20% improvement in the Assessment of Spondyloarthritis International Society Criteria (ASAS20), change from baseline in Bath Ankylosing Spondylitis Functional Index (BASFI) score, and change from baseline in C-reactive protein (CRP) levels from weeks 4–52.

Results

Before matching, 105 patients were treated with GOL IV and 201 patients were treated with IFX. After matching on all covariates, 118 patients were included in the ASAS20 analysis, 96 in the BASFI analysis, and 160 in the CRP analysis. After matching, GOL IV showed significantly greater improvement in ASAS20 response than IFX for weeks 28–44 (e.g., OR = 9.05 [95% CI 1.62–50.4] at week 44) and was comparable in change from baseline in BASFI scores and CRP levels to IFX at all time points. Results were robust for inclusion of different sets of covariates in scenario analyses.

Conclusions

This is the first analysis of its kind to leverage clinical trial data to compare two biologics using PS methods in the treatment of active AS. Overall, GOL IV was associated with greater improvement in ASAS20 response than IFX in patients with AS at 28, 36, and 44 weeks of follow-up.

Key Points • Although intravenous golimumab (GOL IV) and infliximab (IFX) are the only two IV-based tumor necrosis factor (TNF) inhibitors with demonstrated phase 3 clinical efficacy in patients with ankylosing spondylitis (AS), no study has evaluated their comparative efficacy in a head-to-head trial. • Propensity score matching was used to derive indirect treatment comparisons of GOL IV and IFX for ≥ 20% in the Assessment of Spondyloarthritis International Society Criteria (ASAS20), change in Bath Ankylosing Spondylitis Functional Index (BASFI), and change in C-reactive protein (CRP) using individual patient data from the GO-ALIVE and ASSERT phase 3 trials. • Propensity score matched indirect comparisons showed improved relative efficacy of GOL IV compared to IFX; after matching for up to 16 baseline covariates, GOL IV was associated with significantly greater odds of ASAS20 response at weeks 28, 36, and 44 than IFX as well as equivalent changes from baseline in BASFI and CRP. • This novel application of propensity score matching using data from phase 3 trials, the first analysis of its kind in AS, allowed adjustment for important imbalances in prognostic factors between trials to generate estimates of comparative efficacy between GOL IV and IFX in the absence of a head-to-head trial between these treatments.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-05051-1) contains supplementary material, which is available to authorized users.

Oligoadenylate Synthetase 1 enhances DNA sensor cGAS translation to mediate WNV antiviral activity

Interferons inhibit virus replication through the expression of interferon stimulated genes (ISGs). We have found that a specific isoform of one such ISG, Oligoadenylate Synthetase 1 (OAS1) limits host susceptibility to West Nile Virus (WNV) infection through a non-canonical mechanism. This OAS1 isoform (OAS1 P46) in humans is generated due to an alternative splice acceptor site at the C-terminus of OAS1 gene. The SNP rs10774671 at this site has been associated with disease severity to WNV. We show that human OAS1-KO cells have lower basal levels of cGAS protein and can be rescued by OAS1 P46 independent of its enzyme activity. Additionally, through RNA-seq, SILAC, polysome profiling and radiolabeling experiments, we show that OAS1 does not regulate mRNA transcription but instead enhances protein translation of a select set of mRNAs, thereby increasing the steady state and induced levels of specific proteins with antiviral properties. Inducible expression of OAS1 P46 in cGAS-KO cells does not suppress WNV replication, suggesting that the antiviral activity of OAS1 is mediated through cGAS. We also have established functional equivalence between OAS1 P46 and a mouse ortholog, Oas1b (no enzyme activity), which similarly affects WNV susceptibility. Oas1b inhibits WNV infection and pathogenesis in vivo and inhibits WNV infection in vitro in cGAS-dependent manner. Through RNA-protein crosslinking experiments we have identified target mRNAs that bind to OAS1 and have demonstrated increased sensitivity of WNV in Oas1b RNA binding mutants. Our findings suggest a novel mechanism of OAS1 in which it binds to target mRNAs, enhances the translation of these RNAs and limits virus infection.

Abstract A13: Leveraging Zika virus and the immune system to treat glioblastoma

Glioblastoma (GBM) kills most adults within 2 years. One reason for inevitable recurrence is that GBM stem cells (GSCs) are resistant to existing therapies. Additionally, GBM is the hallmark example of an immunotherapy-resistant tumor. Since GSCs share properties with neural stem cells, we investigated whether the natural honing and lytic activity of Zika virus (ZIKV) could be harnessed to target and kill GSCs. We published the first use of ZIKV to kill GSCs: ZIKV kills GSCs in tumors removed from patients, with minimal impact on non-GSC tumor cells and importantly, normal human brain cells were not affected by ZIKV. In vivo, ZIKV more than doubled median survival in immunocompetent mice bearing orthotopic gliomas, and in 40-50% of cases, mice were cured. In new unpublished work, we assessed brains of mice treated with ZIKV and found that treatment induces a robust inflammatory response. Using MHC-I tetramers presenting ZIKV envelope (E) protein or luciferase peptides (expressed in the tumor cells), we found that CD8+ T cells in the region of the tumor respond to both ZIKV and tumor, and anti-tumor CD8+ T cells are increased after ZIKV infection compared to vehicle. Additionally, cured mice were protected against tumor rechallenge, suggesting ZIKV induces immunologic memory that can surveil against recurrence. Using blocking antibodies, we discovered that CD8+ T cells are required for the efficacy of ZIKV, and CD8+ T cells are required for long-term protection. Our findings suggest that ZIKV may be an effective therapy for GBM for two reasons: its direct targeting of treatment-resistant tumor cells in turn produces an antitumor inflammatory response. Such a response may now be further leveraged by immunotherapies.

Citation Format: Arijita Jash, Jennifer Govero, Sharmila Nair, Michael S. Diamond, Milan G. Chheda. Leveraging Zika virus and the immune system to treat glioblastoma [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2019 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(3 Suppl):Abstract nr A13.

A185 ABDOMINAL WALL VARICES: A CASE REPORT

Background

Portal hypertension in cirrhosis results in variable and numerous portosystemic collateral circulations. Computed tomography (CT) and Doppler ultrasound (US) can identify these collateral vessels, especially abdominal wall varices, which can be encountered during a bedside paracentesis.

Aims

Describe a case of traumatic abdominal wall variceal bleed.

Methods

Case report.

Results

A 53 year-old Caucasian male presented to the emergency department (ED) with 4-days of abdominal pain and 2-months of increased abdominal girth. His medical history included Child Pugh Class B alcoholic liver cirrhosis diagnosed 1 year ago. No prior history of ascites, esophageal variceal bleed or hepatic encephalopathy. In the ED, his US showed moderate ascites with right portal vein flow reversal. A diagnostic RLQ paracentesis showed yellow ascitic fluid, no spontaneous bacterial peritonitis (SBP), and he was discharged home with diuretics.

He returned to the ED the next day for increased abdominal girth with a Hb of 103 g/L. A diagnostic RLQ paracentesis showed orange-red ascitic fluid and no SBP. The following day, a therapeutic US-guided paracentesis was attempted in the RLQ and left-lower quadrant LLQ; however, ascitic fluid aspirate was grossly bloody. The procedure was aborted. Hb was 82 g/L and progressively decreased. CT angiogram was performed and showed a 10.7 x 4.7 x 8.0 cm hyperdense fluid in the right paracolic gutter near the paracentesis site, consistent with intraperitoneal hemorrhage (Figure A). The insertion site was seen as abdominal wall musculature focal thickening around abdominal wall varices and no contrast extravasation was seen. Gastroesophageal, splenic hilar and omental varices were seen. Doppler US showed no sonographic signs of active extravasation. Interventional Radiology performed a US-guided paracentesis and aspirated 3650 mL of hemorrhagic fluid. Color Doppler US showed small varices within the subcutaneous soft tissues (Figure A).

The patient later developed hematemesis with an EGD showing a large high-risk esophageal varix actively bleeding that was banded. Given the refractory variceal bleeding, a Minnesota tube was inserted 4 days later and a transjugular intrahepatic portosystemic shunt was inserted the following day. Unfortunately, the patient developed progressive worsening hepatic encephalopy, multi-organ failure and expired 7-days later.

Conclusions

Adjunct imaging modalities such as color flow Doppler US or CT can be used as a screening tool to identify abdominal wall varices and reduce paracentesis bleeding complications.

Funding Agencies

None