Evaluation of Severity of Illness Scores in the Pediatric ECMO Population

Though commonly used for adjustment of risk, severity of illness and mortality risk prediction scores, based on the first 24 h of intensive care unit (ICU) admission, have not been validated in the pediatric extracorporeal membrane oxygenation (ECMO) population. We aimed to determine the association of Pediatric Index of Mortality 2 (PIM2), Pediatric Risk of Mortality Score III (PRISM III) and Pediatric Logistic Organ Dysfunction (PELOD) scores with mortality in pediatric patients on ECMO. This was a retrospective cohort study of children ≤18 years of age included in the Pediatric ECMO Outcomes Registry (PEDECOR) from 2014 to 2018. Logistic regression and Receiver Operating Characteristics (ROC) curves were used to calculate the area under the curve (AUC) to evaluate association of mortality with the scores. Of the 655 cases, 289 (44.1%) did not survive until hospital discharge. AUCs for PIM2, PRISM III, and PELOD predicting mortality were 0.52, 0.52, and 0.51 respectively. PIM2, PRISM III, and PELOD scores are not associated with odds of mortality for pediatric patients receiving ECMO. These scores for a general pediatric ICU population should not be used for prognostication or risk stratification of a select population such as ECMO patients.

Factors associated with the drug-resistant tuberculosis incidence rate in Brazil

SETTING

The selection and transmission of drug-resistant strains of tuberculosis (TB) hamper disease control.

OBJECTIVE

To identify health conditions, demographic and socio-economic factors, as well as individual factors associated with the incidence of drug-resistant TB (DR-TB), in Brazil at the municipal level.

DESIGN

This was an ecological study covering Brazilian municipalities that had reported DR-TB cases in 2014. Associations were evaluated in a multilevel analysis using negative binomial regression.

RESULTS

In the multilevel model, males (incidence rate ratio [IRR] 2.6, 95% confidence interval [CI] 2.3-2.93) and Black persons (IRR 1.82, 95%CI 1.61-2.05) had a higher risk of DR-TB. Compared with those aged 60 years, persons aged 15-59 years (IRR 1.72, 95%CI 1.40-2.11) also had a higher risk. The following contextual factors were associated with the incidence rate (IR) of DR-TB: proportion of previously treated patients (IRR 1.27, 95%CI 1.1-1.5), acquired immune-deficiency syndrome IR (IRR 1.13, 95%CI 1.02-1.25), Municipal Human Development Index (IRR 0.72, 95%CI 0.64-0.81) and the Gini coefficient (IRR 0.86, 95%CI 0.78-0.95).

CONCLUSION

We have identified individual and contextual factors associated with the incidence of DR-TB. Our results may help improve integrated public health interventions aimed at controlling DR-TB in Brazil.

Intestinal occlusion by stenotic neuroendocrine tumours of left colon and concomitant association with small bowel gastrointestinal stromal tumours: A case report

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Gastrointestinal stromal tumours (GIST) and Neuroendocrine tumours (NET) of the gastroenteropancreatic tract are rare neoplasms.

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Treatment for colonic NETs was similar to colonic adenocarcinoma, with segmental resection and lymphadenectomy.

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The associationof GIST and NET is difficult to suspect Serum CgA remains the most important biochemical marker in the diagnostics, monitoring, and establishing the prognosis in colorectal NETs.

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Early diagnosis of concomitant tumors such as GIST and NET will guarantee a better outcome of patients.

Introduction

The association between Gastrointestinal Stromal Tumours (GIST) and Neuroendocrine Tumours (NET) is very rare. These tumours have various clinical expressions and sometimes are asymptomatic. Synchronous NETs and GISTs have been already described in literature in few case reports. On the other hand, there is no mention of concomitant presence of discending colon NEC-G3 and small intestinal GIST.

Presentation of case: we presented a case of a patient with clinical evidence of intestinal occlusion and radiological and intraoperative aspects of an adenocarcinoma of the left colon with a single metastasis on small bowel. The pathology analysis of the tumour showed a stenotic left colon NEC-G3 and a small bowel GIST.

Discussion

In this case report GIST was surgically treated as a small bowel ripetitive lesion and NET as a left colon adenocarcinoma. These tumours may have a similar presentation in terms of symptoms, endoscopic findings and imaging results.

Conclusion

Concomitant NEC and GIST is rare but it is important to investigate patients before surgery in order to distinguish these from other tumours because of the different prognosis.

Neonatal Aortic Arch Reconstruction With Direct Splanchnic Perfusion Avoids Deep Hypothermia

BACKGROUND

Neonatal aortic arch reconstruction, typically performed with deep hypothermia and selective cerebral perfusion, leaves splanchnic organ protection dependent on hypothermia alone. A simplified method of direct in-field descending aortic perfusion during neonatal arch reconstruction permits the avoidance of deep hypothermia. We hypothesize that direct splanchnic perfusion at mild hypothermia provides improved or equivalent safety compared with deep hypothermia and may contribute to postoperative extracardiac organ recovery.

METHODS

Included were 138 biventricular patients aged younger than 90 days undergoing aortic arch reconstruction with cardiopulmonary bypass. Patients were grouped according to perfusion method A (selective cerebral perfusion with deep hyperthermia at 18° to 20°C) or method B (selective cerebral perfusion and splanchnic perfusion at 30° to 32°C). Patient characteristics and perioperative clinical and serologic data were analyzed. Significance was assigned for p of less than 0.05.

RESULTS

Of the 138 survivors, 63 underwent method A and 75 underwent method B. The median age at operation was 8.5 days (range, 6 to 15 days), and median weight was 3.2 kg (range, 2.8 to 3.73 kg), with no significant differences between groups. Cardiopulmonary bypass times were comparable between the two perfusion methods (p = 0.255) as were the ascending aortic cross-clamp times (p = 0.737). The postoperative glomerular filtration rate was significantly different between our groups (p = 0.028 to 0.044), with method B achieving a higher glomerular filtration rate. No significant differences were seen in ventilator time, postoperative length of stay, fractional increase of postoperative serum creatinine over preoperative serum creatinine, and postoperative lactate.

CONCLUSIONS

A simplified method of direct splanchnic perfusion during neonatal aortic arch reconstruction avoids the use of deep hypothermia and provides renal protection at least as effective as deep hypothermia.