Alison Keenan

Effects of Unfractionated Heparin and Glycoprotein IIb/IIIa Antagonists Versus Bivalirdin on Myeloperoxidase Release From Neutrophils

Objectives—The objective of this study was to determine whether adjunctive therapy during percutaneous coronary intervention (PCI) affects markers of systemic inflammation or platelet activation. Despite different mechanisms of action, direct-thrombin inhibition with bivalirudin during PCI provided similar protection from periprocedural and chronic ischemic complications as compared with unfractionated heparin (UFH) plus planned use of GPIIb/IIIa antagonists in the REPLACE-2 and ACUITY trials. Methods and Results—Patients undergoing nonurgent PCI of a native coronary artery were randomized to receive adjunctive therapy with bivalirudin or UFH+eptifibatide. Interleukin (IL)-6 and C-reactive protein (CRP) transiently increased in both groups after PCI. In the UFH+eptifibatide, but not the bivalirudin group, myeloperoxidase (MPO) levels were elevated 2.3-fold above baseline (P=0.004) immediately after PCI. In an in vitro assay, heparin and to a lesser extent enoxaparin, but not bivalirudin or eptifibatide, stimulated MPO release from and binding to neutrophils and neutrophil activation. A mouse model of endoluminal femoral artery denudation was used to investigate further the importance of MPO in the context of arterial injury. Conclusions—Adjuvant therapy during PCI may have undesired effects on neutrophil activation, MPO release, and systemic inflammation.

Vitamin B12 deficiency in patients after enterocystoplasty

INTRODUCTION Serum B12 deficiency is a known sequlae of enterocystoplasty. The complications of B12 deficiency include megaloblastic anemia, neuropsychiatric disease, and demyelinating diseases such as peripheral neuropathy. Some studies have suggested that underlying disease states may be more important than enteric absorptive capacity in predicting acquired B12 deficiency. A 38% incidence of low or low-normal serum B12 in patients who have undergone enterocystoplasty has previously been reported, and oral B12 supplementation has been demonstrated to be an effective short-term therapy; however, the long-term results remain unclear. AIMS This study hypothesized that oral vitamin B12 supplementation in patients with B12 deficiency following enterocystoplasty is an effective long-term treatment. Additionally, it sought to determine if underlying disease state predicts B12 deficiency following enterocystoplasty. DESIGN Children who underwent enterocystoplasty at the present institution prior to August 2007 were reviewed. Patients with non-ileal augment, insufficient follow-up or hematologic disorders were excluded. Patients with low or low-normal B12 levels were included. Treatment consisted of daily oral therapy of 250 mcg or monthly parenteral therapy of 1000 mcg IM. Separately, the institutional database of 898 patients who underwent enterocystoplasty was searched and patients with at least one post-operative B12 level were highlighted. The indication for enterocystoplasty was classified as neuropathic or non-neuropathic. RESULTS Twenty-three patients met inclusion criteria. The mean follow-up was 49 months (range 5-85) following initial abnormal B12 level. On the last follow-up, 4/23 (17%) patients had normal serum B12 levels. No patients reported sequelae of long-term B12 deficiency. In the secondary investigation, 113 patients met inclusion criteria. A total of 101 had neuropathic indications for enterocystoplasty, and 12 had non-neuropathic indications. At any time during follow-up, 48/101 (47.5%) neuropathic patients had low or low-normal B12 levels, and 4/12 (33.3%) non-neuropathic patients had low or low-normal B12 levels during follow-up (P = 0.54) (Figure). DISCUSSION The initial success of oral B12 deficiency treatment following enterocystoplasty does not persist over time. This contradicts previous results with short duration follow-up. Underlying disease as the indication for enterocystoplasty did not predict B12 deficiency risk. The study was limited by the small number of patients with B12 deficiency who were started on treatment, as well as by the small number of patients with non-neuropathic indications for enterocystoplasty. CONCLUSION The aims of the study were met. Further investigation is required to assess predictors of B12 deficiency following enterocystoplasty.

Readmission characteristics of elective pediatric circumcisions using large-scale administrative data

INTRODUCTION AND BACKGROUND Elective circumcision is a common procedure, known to be safe and associated with minimal morbidity. There are few data reporting the rates of readmission and reoperation following elective circumcision. OBJECTIVE We sought to define the rates of readmission and reoperation in the first 7 days following circumcision to accurately counsel families about the risks of this elective procedure. STUDY DESIGN The Pediatric Health Information System (PHIS) was interrogated from 2004 to 2013 for all ambulatory, elective circumcisions (ICD-9 CM code of 640). We assessed readmission with respect to age, insurance status, race, readmission diagnosis, time to readmission, and seasonal differences (due to higher rates of all-cause hospital admissions). We performed logistical regression analysis with a dependent variable of readmission within 7 days and independent variables of age, race, month of admission, and insurance status. RESULTS We identified 95,046 circumcisions from 2004 to 2013 performed in ambulatory surgery centers. Of those, 2906 (3.1%) of patients had an additional encounter at the same facility within 7 days. A total of 2409 (2.4%) of encounters were ER visits, and 253 (0.3%) were encounters for hospital admission or observation. One hundred and thirty-two patients (0.1%) underwent a second ambulatory procedure within the first 7 days following circumcision. Black patients (OR 1.26, p < 0.001) and patients on Medicaid (OR 1.63, p < 0.001) were more likely to seek care of any kind at the same institution within 7 days of the original circumcision operation. No difference was found with regard to time of year on logistic regression. Older age at circumcision was associated with increased likelihood of reoperation compared to children <1 year, with children 12-18 years old having an OR of 1.91 (p = 0.033). DISCUSSION We present a descriptive study of clinical events occurring at the same tertiary childrens hospital within the first 7 days following more than 95,000 elective postneonatal circumcisions. Limitations include a cohort generated from a single set of ICD-9 codes, and a follow-up of 7 days. CONCLUSION Elective circumcision remains a safe procedure with a readmission rate of 0.3%, and a reoperative rate of 0.1%. However, a relatively high percentage of patients (3.1%) will have a secondary encounter within the first 7 days following circumcision, most of them seeking care in an ER, although not necessarily for circumcision-related reasons. These may be useful data when counseling patients.

Long-Term Outcomes Following Bladder Augmentation in Children with Neurogenic Bladder

Bladder augmentation remains the final step in the management of refractory neurogenic bladder (NGB) for many children who have failed medical management. The long-term risks and benefits of augmentation surgery are important to understand when counseling patients about management options and when following augmented patients postoperatively. Benefits of bladder augmentation include improved continence, decreased risk of upper tract deterioration, possibly improved quality of life, and even reduced risk of renal-related mortality. However, risks are not trivial and include the potential need for further surgery, calculi formation, bladder perforation, acid-base disturbances, vitamin B12 deficiency, and possibly malignancy. Therefore, patients considered for augmentation should be well counseled and selected and subsequently must be followed closely by an experienced urologist for the duration of their lives.

MP54-19 COMPARISON OF COST AND COMPLICATIONS IN OPEN VERSUS ROBOTIC URETERAL REIMPLANTATION IN AMERICAN CHILDREN'S HOSPITALS

and in 1/20 (5.0%) patients who did not (p1⁄41.0). There were no urinary tract infections occurring within one week of stent removal in either group. CONCLUSIONS: The administration of extended prophylactic antibiotics showed no significant impact on the rate of urinary tract infection following laparoscopic pyeloplasty with ureteral stent placement. Furthermore, up to 5.5% of patients may still have asymptomatic bacteriuria at stent removal despite antibiotic prophylaxis.

Sacral Neuromodulation in Children

Sacral neuromodulation (SNM) has emerged as a treatment option for refractory lower urinary tract and bowel dysfunction in children. SNM is typically reserved for a select population of children who have failed an extended period of behavioral modification, biofeedback, and pharmacologic therapy. The surgical techniques for SNM in children are analogous to those in adults and include both one- and two-stage procedures as well as a peripheral nerve evaluation with the InterStim® system (Medtronic, Minneapolis, MN). Most studies have observed not only an improvement in symptoms and quality of life in children undergoing SNM for non-neurogenic and neurogenic lower urinary tract dysfunction but also a much higher reoperative rate than in adults. Further high-quality research is necessary to corroborate the results of earlier studies and to better define the indications for SNM in children.

A Novel Colonoscopic Approach for the Management of a Malone Antegrade Continence Enema Channel, Which Cannot Be Catheterized in the Immediate Postoperative Period: A Case Report

Early Malone antegrade continence enema (MACE) complications are rare, but can be devastating, particularly if they involve loss of the channel. Management of these complications is not well described. We report on a patient who had her MACE channel successfully salvaged in the immediate postoperative period using a colonoscopic retrograde wire and catheter placement after failing antegrade percutaneous endoscopic management. To our knowledge, this is the first report of a novel, colonoscopic, minimally invasive technique of managing select MACE channels, which cannot be otherwise recatheterized. We also review the management of postoperative MACE complications.