A History of Umbilical Vein Catheterization Does Not Preclude Children from a Successful Meso-Rex Bypass

INTRODUCTION

 Umbilical vein catheterization (UVC) can cause portal venous thrombosis, leading to the development of extrahepatic portal venous obstruction (EHPVO) and portal hypertension (PHT). The feasibility of the Meso-Rex bypass (MRB) for the treatment of EHPVO in patients with a history of UVC has been questioned. We compared the feasibility of performing an MRB in patients with or without a history of previous UVC.

METHODS

 A retrospective review of patients with EHPVO and known UVC status explored for a possible MRB at our institution was performed (1997-2022). Patients were categorized in two groups: with (UVC(+)) or without (UVC(-)) a history of UVC for comparison. A p-value less than 0.05 was considered significant.

RESULTS

 One hundred and eighty-seven patients were included (n = 57 in UVC(+); n = 130 in UVC(-)). Patients in the UVC group were significantly younger at surgery and the incidence of prematurity was higher. Other risk factors for the development of EHPVO were similar between the groups, but only history of UVC could predict the ability to receive MRB (odds ratio [OR]: 7.4 [3.5-15.4]; p < 0.001). The success rate of MRB was significantly higher in patients with no history of UVC (28/57 [49.1%] in UVC(+) vs. 114/130 [87.7%] in UVC(-); p < 0.001). However, MRB patency at discharge (25/28 [89.3%] in UVC(+) vs. 106/114 [94.7%] in UVC(-); p = 0.3) was equally high in both groups.

CONCLUSION

 Our results indicate that a history of UVC is not a contraindication to MRB. Half of the patients were able to successfully receive an MRB. Patients with symptomatic PHT from EHPVO should not be excluded from consideration for MRB based on UVC history.

Outcomes after ABO incompatible pediatric liver transplantation are comparable to ABO identical/compatible transplant

Background

ABO incompatible (ABOi) liver transplantation (LT) was initially associated with a higher incidence of vascular, biliary, and rejection complications and a lower survival than ABO compatible (ABOc) LT. Various protocols have been proposed to manage anti-isohemagglutinin antibodies and hyperacute rejection. We present our experience with a simplified protocol using only plasmapheresis.

Methods

A retrospective review of all patients who received an ABOi LT at our institution was performed. Comparisons were made based on era (early: 1997-2008, modern: 2009-2020) and severity of disease (status 1 vs. exception PELD at transplant). A pair-matched comparison was done to patients who received an ABOc LT. p < 0.05 was considered significant.

Results

17 patients received 18 ABOi LT (3 retransplants). Median age at transplant was 7.4 months (1.1-28.9). 66.7% patients were listed as status 1. Hepatic artery thrombosis (HAT) occurred in one patient (5.6%), there were 2 cases of portal vein thrombosis (PVT) (11.1%), and 2 biliary strictures (11.1%). Patient and graft survival improved in the ABOi modern era, although not significantly. In the pair-matched comparison, complications (HAT p = 0.29; PVT p = 0.37; biliary complications p = 0.15) and survival rates were similar. Patient and graft survivals were 100% in the non-status 1 ABOi patients compared to 67% (p = 0.11) and 58% (p = 0.081) respectively for patients who were transplanted as status 1.

Conclusion

ABO incompatible liver transplants in infants with a high PELD score have excellent outcomes. Indications for ABO incompatible transplants should be liberalized to prevent deaths on the waiting list or deterioration of children with high PELD scores.

Fluid balance in pediatric postoperative liver transplant recipients

BACKGROUND

Positive fluid balance (FB) is associated with poor outcomes in critically ill children but has not been studied in pediatric liver transplant (LT) recipients. Our goal is to investigate the relationship between postoperative FB and outcomes in pediatric LT recipients.

METHODS

We performed a retrospective cohort study of first-time pediatric LT recipients at a quaternary care children's hospital. Patients were stratified into three groups based on their FB in the first 72 h postoperatively: <10%, 10-20%, and > 20%. Outcomes were pediatric intensive care unit (PICU) and hospital length of stay, ventilator-free days (VFD) at 28 days, day 3 severe acute kidney injury, and postoperative complications. Multivariate analyses were adjusted for age, preoperative admission status, and Pediatric Risk of Mortality (PRISM)-III score.

RESULTS

We included 129 patients with median PRISM-III score of 9 (interquartile range, IQR 7-15) and calculated Pediatric End-stage Liver Disease score of 15 (IQR 2-23). A total of 37 patients (28.7%) had 10-20% FB, and 26 (20.2%) had >20% FB. Greater than 20% FB was associated with an increased likelihood of an additional PICU day (adjusted incident rate ratio [aIRR] 1.62, 95% CI: 1.18-2.24), an additional hospital day (aIRR 1.39, 95% CI: 1.10-1.77), and lower likelihood of a VFD at 28 days (aIRR 0.85, 95% CI: 0.74-0.97). There were no differences between groups in the likelihood of postoperative complications.

CONCLUSIONS

In pediatric LT recipients, >20% FB at 72 h postoperatively is associated with increased morbidities, independent of age and severity of illness. Additional studies are needed to explore the impact of fluid management strategies on outcomes.

Identification of Early Clinical and Histological Factors Predictive of Kasai Portoenterostomy Failure

Background: It is impossible to predict which patients with biliary atresia (BA) will fail after Kasai portoenterostomy (KPE). We evaluated the predictive nature of pre-KPE clinical and histological factors on transplant-free survival (TFS) and jaundice clearance. Methods: A retrospective review of patients who received a KPE at our institution (1997−2018) was performed. Primary outcomes were two-year TFS, five-year TFS, and jaundice clearance 3 months after KPE. p < 0.05 was considered significant. Results: Fifty-four patients were included in this study. The two-year TFS was 35.1%, five-year TFS was 24.5%, and 37% patients reached a direct bilirubin (DB) ≤ 2.0 mg/dL 3 months post KPE. The median age at biopsy was younger in the five-year TFS (39.0 (24.5−55.5) vs. 56.0 days (51.0−67.0), p = 0.011). Patients with DB ≤ 1.0 mg/dL 3 months after KPE were statistically younger at biopsy (DB ≤ 1.0 44.0 (26.0−56.0) vs. DB > 1.0 56.0 days (51.0−69.0), p = 0.016). Ductal plate malformation was less frequent in the five-year TFS (16/17, 94.1%, vs. 1/17, 5.9%, p = 0.037). Portal fibrosis (19/23, 82.6%, vs. 4/23, 17.4%, p = 0.028) and acute cholangitis (6/7, 85.7%, vs. 1/7, 14.3%, p = 0.047) occurred less frequently in two-year TFS. Conclusion: Older age at biopsy, acute cholangitis, portal fibrosis, and ductal plate malformation were associated with lower native liver survival. Evaluation in a larger study population is needed to validate these results.

Early thrombotic and hemorrhagic complications associated with a risk-adjusted postoperative anticoagulation protocol after pediatric liver transplantation

BACKGROUND

Systemic anticoagulation after pediatric liver transplantation (pLT) is believed to reduce the incidence of vascular thrombosis, but it may also cause an increase in hemorrhagic complications.

PROCEDURE

A 5-year retrospective review of pLT done at our institution was performed (2014-2018). The occurrence of early hemorrhagic and thrombotic complications was compared when using low-dose or high-dose anticoagulation after transplant (p < .05 considered significant).

RESULTS

Sixty-nine patients received 73 transplants during the study period. Median age at transplant was 2.3 years (40 days to 18.5 years). Low-dose anticoagulation was utilized in 71% cases. Additionally, six patients were converted from low-dose to high-dose anticoagulation because of a thrombotic event or concerns for suboptimal vascular inflow. Postoperative anticoagulation was discontinued in 18 occurrences due to bleeding (low dose 19%, high dose 47% vs. low dose to high dose 17%, p = .085). Surgical take back for bleeding occurred in 17 occasions (low dose 13.5%, high dose 53% vs. low dose to high dose 33%, p = .005). The overall incidence of hepatic artery thrombosis (HAT) and portal vein thrombosis were each 5.5%, respectively. While patient survival was not statistically different between groups, graft survival was significantly lower in the high-dose group (low dose 93%, high dose 73% vs. low dose to high dose 100%, p = .046). However, graft losses from HAT were similar between groups (low dose 2%, high dose 7% vs. low dose to high dose 0%, p = .56).

CONCLUSION

The use of a standardized risk-adjusted anticoagulation protocol after pLT is associated with a low occurrence of thrombotic and hemorrhagic complications. High-dose anticoagulation leads to more bleeding, but those risks outweigh the risks of possible graft loss.

[Interdigital pilonidal sinus ("barber's disease")--a rare occupational disease]

Barber's disease is produced by short hairs that penetrate the interdigital spaces of the hands. The following chronic inflammatory reaction causes fistulas or sinuses and cysts. We present the case of a patient with interdigital pilonidal sinuses of all web spaces in both hands. Such an extensive case of this occupational disease has so far not been reported.

Mother-infant interaction and breastfeeding outcome 6 weeks after birth

OBJECTIVE

This study explored the relationship of early postpartum maternal-infant interactions to breastfeeding outcome at 6 weeks postpartum.

DESIGN

Prospective, comparative descriptive study.

SETTING

Women, Infants, and Children Supplemental Nutrition Program and Comprehensive Perinatal Services Programs in northern California.

PARTICIPANTS

Forty-two Latina participants were recruited in the 3rd trimester of pregnancy. Eligibility criteria included age 18 years or older, primiparous at recruitment, antepartum desire to breastfeed 8 weeks or longer postpartum, planned hospital birth, full-term vaginal birth of a healthy newborn, and an uncomplicated, immediate postpartum course for mother and newborn, including being discharged together.

MAIN OUTCOME MEASURES

The study examined breastfeeding dyads' early postpartum scores on Barnard's Nursing Child Assessment Feeding Scale (NCAFS) in relation to breastfeeding outcome 6 weeks postpartum. NCAFS tests were performed 28-90 hours postpartum in the participants' homes, and breastfeeding status was assessed by phone contact 6 weeks postpartum.

RESULTS

Dyads continuing to breastfeed at 6 weeks postpartum had significantly higher early postpartum NCAFS scores than did dyads who had weaned from the breast by 6 weeks postpartum.

CONCLUSIONS

Optimal maternal-infant interactions, as evidenced by higher scores on Barnard's NCAFS, were related to longer breastfeeding duration. Lower scores on the NCAFS, suggesting difficulties in maternal-infant interaction, were related to weaning earlier than planned.

"Current topics in health sciences librarianship": a pilot program for network-based lifelong learning

The long-term objective of this project is to make health sciences librarians more effective in their role by using emerging technologies to deliver timely continuing education (CE) programs to them regardless of their physical location. The goals of the one-year planning project at the William H. Welch Medical Library are to plan, implement, and evaluate a pilot CE program that includes (1) a three-day general-interest session organized in four tracks: Market Forces and Management, Information Technology and the Internet, Publishing and Copyright, and Education; (2) a one-day special topic session on the Informatics of the Human Genome Project; and (3) an electronic poster session in parallel with the general-interest session. The program will be offered in three simultaneous formats: (1) on-site, in a distance-learning classroom in Baltimore; (2) as a telecourse, in a similar classroom outside Washington, DC; and (3) online, via the World Wide Web. An electronic proceedings of the entire program will be published on the Web to serve as a continuously available CE resource for health sciences librarians. This paper gives an overview of the planning process, presents a status report on the programmatic and technical implementation of the pilot project at its midpoint, and discusses future directions for the program.

Treatment of partial thickness burns of the hand with the preshaped, semipermeable Procel Burn Cover: results of a multicentre study in the burn centres of Berlin, Duisburg and Munich

The results of a prospective clinical study conducted in three German burn centres are reported. The subject of the evaluation was to show the effectiveness of a new, preshaped, semipermeable burn dressing that is resistant to fluids and bacteria but highly permeable to vapour. The dressing was used in conjunction with 1 per cent silver sulphadiazine cream in treating partial thickness burns of the hand. In 49 patients, 72 partial thickness burned hands were treated. The application proved to be very easy. The time for a dressing change was short (5-10 min). The duration of treatment was 13 days on average. Complications due to infections did not occur. Because of the semipermeable properties of the dressing material, skin macerations occurred in only a few instances (13 per cent) as a result of inappropriate cream application or extremely high exudation rates, and these did not adversely affect the healing process. Patients achieved the ability to perform activities of daily living early with positive results for the patients, the physician and the nursing team.

[Surgical approaches in the treatment of burns]

The indication for operative treatment of third-degree burns, necrectomy and the possibilities for closing the defects are discussed. Special problems have to be considered in the operative therapy of third-degree hand injuries. In cases of extensive burns the donor areas are mostly limited and a biological dressing must be used. Different kinds of wound coverage are available for the final autologous skin reconstruction in these patients. Last but not least, the right postoperative immobilisation of both the patient and the transplanted areas is very important for successful skin grafting.

Teaching literature searching in the context of the World Wide Web

As part of the required curriculum for medical students, we devised a literature-searching practicum that has been used for two years. In both years, we stressed going beyond the skills needed for using a particular searching program, towards a more conceptual approach to information searching. In the first year, the practicum was taught in a traditional lecture/hands-on format. In the second year, the lecture was replaced by a World Wide Web-based tutorial (http:@www.welch.jhu.edu/Education/tutorials/pra cticum.html). To our knowledge, this is the first Web-based resource intended to teach students about appropriate use of search technology. Comparison of student evaluations showed no difference in attitude toward the two versions of the practicum, and observation of student performance suggested similar levels of proficiency. We conclude that placing these educational materials on the Web (1) makes us practice what we preach; (2) is as effective as traditional teaching methods; and (3) gives students a resource for reinforcement learning.

The GDB Human Genome Data Base: a source of integrated genetic mapping and disease data

The GDB Human Genome Data Base refers collectively to GDB and OMIM, Online Mendelian Inheritance in Man. GDB and OMIM are linked databases that provide an international repository for information generated by the Human Genome Initiative. GDB contains human gene mapping data, while OMIM offers the text of Dr. Victor A. McKusick's catalog of genetic disease and phenotype descriptions. These databases, updated and edited continuously, integrate bibliographic and full-text information with several types of mapping data. They are accessible through a flexible interface and are available through SprintNet and the Internet to the scientific community without cost. This paper provides an overview of the context, development, structure, content, and use of these databases.

[Reconstruction in burn injuries]

In third-degree burn injuries vital, functional or esthetic indications require surgical therapy. In order to keep the risk of infection as low as possible it is necessary to begin with the necrectomy as soon as possible. Extent and depth of the damaged tissue, the degree of the wound infection as well as the patient's physical condition decide whether the defect should be covered temporarily or whether an autologous splitskin transplantation should be performed. In addition to stripe transplants meshgraft-transplants of different sizes have proved to be very successful in surgery of burn injuries.