A novel method of mechanical thrombectomy utilizing a stent retriever device with continuous aspiration prior to intracranial vascular embolectomy technique for acute superior mesenteric artery occlusion: A case report

Acute superior mesenteric artery (SMA) occlusion resulting from a thrombus formation carries a high mortality risk and therefore immediate diagnosis and treatment are warranted. In recent years, mechanical thrombectomy by interventional radiology has become a viable treatment option if the occlusion has not advanced to intestinal necrosis. We present a rare and interesting case involving a patient with acute SMA occlusion which was completely recanalized by mechanical thrombectomy utilizing a stent retriever device and the continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE) technique. The CAPTIVE technique has become widely adopted in recent years to treat large vessel occlusions in the cerebrovascular region due to thrombi. First, a microcatheter with a microguidewire is advanced through the occlusive thrombus coaxially with an aspiration catheter. Next, a stent retriever is deployed in the thrombotic body and the aspiration catheter is advanced adjacently to the proximal part of the thrombus with strong aspiration until no backflow is present. After checking for backflow from the aspiration catheter, the microcatheter delivering the stent is removed to increase the aspiration force. Finally, the stent retriever and the aspiration catheter are retrieved as a single unit. An 87-year-old female patient with a history of atrial fibrillation (AF), chronic heart failure, aortic valve stenosis, hypertension, type2 diabetes mellitus, and hyperlipidemia was admitted to our hospital complaining of sudden onset upper abdominal pain, vomiting, and watery diarrhea. On arrival, her body temperature was 36.0°C (96.8°F), blood pressure was 131/75 mmHg, heart rate was 115 beats/min with AF rhythm, and her white blood cell count was 18,100 cells/μL. A contrast-enhanced computed tomography revealed a contrast defect in the SMA which we later diagnosed as an acute occluding thrombus of the SMA. Initially, we attempted aspiration of the thrombus but were unsuccessful, so we transitioned to mechanical thrombectomy utilizing a stent retriever device with CAPTIVE technique which rapidly and completely recanalized the occluded SMA. After the procedure, the patient’s abdominal pain immediately subsided. Normal stool was observed 2 days after the procedure and oral feeding was subsequently initiated. Twelve days after the procedure, the patient was discharged from the hospital in good health.

A promising new predictive factor for detecting bowel resection in childhood intussusception: the lymphocyte-C-reactive protein ratio

Background The most critical concern for the management of childhood intussusception is bowel resection due to intestinal ischemia and necrosis. The early prediction of this problem is of great importance. We investigated the value of various combinations of inflammatory factors to predict intestinal necrosis and resection. Methods We retrospectively reviewed the medical records of pediatric patients with intussusception who underwent surgical management. During the research period, 47 patients who underwent intestinal resection due to intestinal necrosis and 68 patients who did not undergo intestinal resection were enrolled. We evaluated the diagnostic value of various combinations of inflammatory markers from preoperative laboratory analyses using the receiver operating characteristic (ROC) method. Results In the current cohort, 115 patients underwent operations for intussusception; among them, 47 patients (40.9%) underwent intestinal resections. In the patients with intestinal resection, the neutrophil count(p = 0.013), CRP level(p = 0.002), platelet–lymphocyte ratio (PLR, p = 0.008), NLR (neutrophil–lymphocyte ratio, p = 0.026), and LCR (lymphocyte–CRP ratio, p < 0.001) values were significantly higher than those in the patients without any resection. The receiver operating characteristic (ROC) analysis results showed that the combination of lymphocytic count along with C-reactive protein levels (LCR) demonstrated the highest correlation with intestinal resection due to intussusception compared with other parameters in the patients, with a sensitivity of 0.82 (0.73–0.86) and specificity of 0.80 (0.57–0.94) for the diagnosis of strangulation. Conclusion The preoperative LCR level is a useful marker to predict the need for intestinal resection due to intestinal necrosis in patients with intussusception.

Lack of Cathepsin D in the Central Nervous System Results in Microglia and Astrocyte Activation and the Accumulation of Proteinopathy-related Proteins

Neuronal ceroid lipofuscinosis is one of many neurodegenerative storage diseases characterized by excessive accumulation of lipofuscins. CLN10 disease, an early infantile neuronal ceroid lipofuscinosis, is associated with a gene that encodes cathepsin D (CtsD), one of the major lysosomal proteases. Whole body CtsD-knockout mice show neurodegenerative phenotypes with the accumulation of lipofuscins in the brain and also show defects in other tissues including intestinal necrosis. To clarify the precise role of CtsD in the central nervous system (CNS), we generated a CNS-specific CtsD-knockout mouse (CtsD-CKO). CtsD-CKO mice were born normally but developed seizures and their growth stunted at around postnatal day 23±1. CtsD-CKO did not exhibit apparent intestinal symptoms as those observed in whole body knockout. Histologically, autofluorescent materials were detected in several areas of the CtsD-CKO mouse’s brain, including: thalamus, cerebral cortex, hippocampus, and cerebellum. Expression of ubiquitin and autophagy-associated proteins was also increased, suggesting that the autophagy-lysosome system was impaired. Microglia and astrocytes were activated in the CtsD-CKO thalamus, and Inducible nitric oxide synthase (iNOS), an inflammation marker, was increased in the microglia. Interestingly, deposits of proteinopathy-related proteins, phosphorylated α-synuclein and Tau protein, were also increased in the thalamus of CtsD-CKO infant mice. Considering these results, it is likely that the CtsD-CKO mouse is a useful mouse model to investigate the contribution of cathepsin D to the early phases of neurodegenerative diseases in relation to lipofuscins, proteinopathy-related proteins and activation of microglia and astrocytes.

The diagnosis and treatment of retrograde intussusception: a single-centre experience

Background/Purpose To investigate the clinical manifestations, treatments of retrograde intussusception and summarize the experience. Methods Children with retrograde intussusception treated in our hospital from January 2011 to January 2021 were retrospectively analysed. Demographics, clinical manifestations, preoperative colour Doppler ultrasound (CDU) findings, findings during surgery and follow-up results were collected. Results A total of 4719 cases of intussusception were treated in our department, including 12 cases of retrograde intussusception (0.25%). There were 8 males and 4 females.The age ranged from 4.1 to 14.3 months, with an average of (8.3 ± 2.8) months.; The weight ranged from 5.5 to 12.6 kg, with an average of (9.4 ± 2.3) kg; The onset time ranged from 6 to 15 h, with an average of (10.0 ± 2.4) h. All the children received CDU examination before surgery, and in one case, the possibility of 2 intussusception masses was considered. Emergency surgical exploration was performed after the failure of air enema reduction. During the operation, multiple types of intussusception were found (coincidence of anterograde and retrograde intussusception). The pattern of anterograde intussusception was all ileo-ileo-colic variety and the retrograde intussusception was proximal sigmoid colon into descending colon. All the children were successfully reduced by manual reduction without intestinal necrosis or intestinal malformation. All children were discharged 6–7 days after surgery, and had no recurrence after 3–6 months of follow-up. Conclusions Retrograde intussusception is easily misdiagnosed before surgery. During air enema, if the intussusception mass was fixed and did not move with increasing pressure, we should be aware of the possibility of retrograde intussusception, and the enema pressure should not be too large to avoid intestinal perforation. If the intraoperative position of the intussusception mass was not consistent with that of the preoperative enema, it was recommended to use bimanual examination to explore whether there was still a mass in the abdominal cavity to avoid misdiagnosis.

Association Between Platelet-to-Lymphocyte Ratio and Preterm Necrotizing Enterocolitis

Introduction: Necrotizing enterocolitis (NEC) is a fatal condition for very-low-birth-weight infants. Necrotizing enterocolitis is a multi-factor phenomenon that results in intestinal mucosal damage and leads to intestinal necrosis. However, sensitive laboratory indicators for NEC are lacking, making early diagnosis difficult. This study aimed to explore the relationship between the platelet-to-lymphocyte ratio (PLR) and NEC in preterm neonates to enable an earlier diagnosis of the condition.Methods: This was a retrospective case–control study of preterm neonates diagnosed with NEC between January 2018 and December 2019 in the West China Second University Hospital. Controls were selected from preterm neonatal intensive care unit (NICU) graduates, and they were matched for gestation and year of birth to the preterms diagnosed without NEC. In total, 93 and 107 infants were included in the NEC and control groups, respectively. Empowerstats analysis was used to identify the association between PLR and preterm NEC.Results: The NEC group had significantly higher PLR levels than the control group. PLR &gt; 100 within 1 week before NEC diagnosis was a risk factor for NEC. There was a positive connection between PLR and preterm NEC. A PLR of &gt;100 was determined as the optimal cutoff for predicting preterm NEC, with patients with PLR &gt;100 having a higher risk of NEC [odds ratio (OR): 18.82 (95% confidence interval (CI): 2.93–120.98), p = 0.002].Conclusions: A PLR of &gt;100 within 1 week after clinical abnormalities is associated with a high risk of NEC in preterm neonates.

997. RLS-0071 Improves Survival in a Rat Model of Intestinal Necrosis

Background Intestinal necrosis and perforation are potentially life-threatening medical conditions that can lead to bacterial sepsis and systemic inflammatory response syndrome. Various etiologies can compromise the intestinal wall causing leakage of luminal contents including enteric bacteria and precipitate aggressive immunological responses including the complement system and neutrophils. RLS-0071 is a peptide inhibitor of the classical and lectin pathways and known modulator of various neutrophil mediated effectors including myeloperoxidase activity and NETosis. Methods In this study we evaluated the extent to which immunomodulation via inhibition of the complement system and neutrophil effectors would alter survival in the setting of intestinal necrosis. Adolescent male Long-Evans rats were subject to cecal ligation and puncture (CLP) with one cohort receiving 40 mg/kg of RLS-0071 thirty minutes after surgery while the control group received no treatment. Survival of the rats was then assessed up to 5 days after surgery. Results Animals treated with RLS-0071 demonstrated nearly 1.5-fold increase in survival compared to the untreated group. In order to further elucidate the increase in survival we explored inflammatory responses as assessed by markers of NETosis i.e., free DNA in plasma, and the pro-inflammatory cytokine, IL-6. A reduction in blood levels of free DNA and the inflammatory cytokine IL-6 were observed for animals treated with RLS-0071. RLS-0071 increases survival of rats after cecal ligation Kaplan-Meier survival curve assessment. The red line indicates the outcome after 75% CLP in animals not receiving treatment (n=13), whereas red curves represent the outcome after animals received a single dose of 40 mg/kg RLS-0071 (n=11). RLS-0071 reduces free DNA levels in the blood Plasma was isolated before surgery (pre-bleed) (n=7) and from animals subject to CLP with (n=4) and without (n=3) RLS-0071 administration 24 hours post-surgery. Plasma samples were incubated with PicoGreen. Fluorescence was read at an excitation wavelength of 485 nm and an emission wavelength of 520nm in a microplate reader. Data are means and standard error of the means RLS-0071 reduces IL-6 levels in the blood Plasma was isolated before surgery (pre-bleed) (n=8) and from animals subject to CLP with (n=3) and without (n=5) RLS-0071 administration 24 hours post-surgery. Plasma samples were analyzed in an IL-6 ELISA according to the manufacturer’s instructions. Data are means and standard error of the means. Conclusion The results of these experiments demonstrate that RLS-0071 can increase survival after intestinal perforation by multi-pronged modulation of complement activation, neutrophil immune mechanisms and cytokine mediated inflammatory responses. Disclosures Kenji Cunnion, MD, MPH, ReAlta Life Sciences Inc (Board Member, Employee, Shareholder) Parvathi Kumar, MBBS, ReAlta Life Sciences Inc (Employee) Brittany Lassiter, BS, ReAlta Life Sciences Inc (Employee) Katherine LaValle, DVM, ReAlta Life Sciences Inc (Employee) Neel Krishna, PhD, ReAlta Life Sciences Inc (Employee, Shareholder)

The Impact of Berberine on Intestinal Morphology, Microbes, and Immune Function of Broilers in Response to Necrotic Enteritis Challenge

The objective of this study was to explore the therapeutic effects of berberine on necrotic enteritis (NE) in broilers caused by Clostridium perfringens. A total of 240 1-day-old Arbor Acres chicks were divided into four groups, as negative controls (NC), positive controls (PC), berberine- (BER-) treated, or lincomycin- (LMY-) treated groups. Broilers were challenged with C. perfringens at 15-21 days of age, followed by BER or LMY supplied in drinking water for 7 days. Experimental results showed that C. perfringens infection significantly decreased growth performance and increased intestinal necrosis index and the number of C. perfringens present to 6.45 Log10CFU/g ( P < 0.001 ). Proinflammatory cytokines in the ileum were significantly increased, but the expression of ileal tight junction proteins occludin and claudin-1 was significantly reduced. Both BER and LMY ameliorated some of these observations. Compared with the PC group, the number of C. perfringens in the cecum was significantly decreased following treatment ( P < 0.001 ), and growth performance and small intestine morphology were similar to those of the NC group ( P > 0.05 ). IL-1β, IL-6, and TNF-α levels as well as occludin and claudin-1 expression were also significantly improved ( P < 0.05 ). BER has the potential to replace antibiotics for NE caused by C. perfringens.

A Promising New Predictive Factor for Detecting Bowel Resection in Childhood Intussusception: Lymphocyte-C Reactive Protein Ratio

Background: The most critical concern for management of childhood intussusception is the bowel resection due to the intestinal ischemia and necrocis. It is of great importance for early prediction of this problem. We investigate the value of various combinations of inflammatory factors to predict the intestinal necrocis and resection.Methods: We retrospectively reviewed the medical records of pediatric patients with intussusception, which undergone surgical management. During the research period, 47 patients undergone intestinal resection due to intestinal necrocis and 68 patients without intestinal resection were enrolled. We evaluated the diagnostic values of various combination of inflammatory markers from preoperative period laboratory analyses using the receiver operating characteristic (ROC) method.Results: In the current cohort, 115 patients were operated for intussusception, among them, 47 patients (40.9%) undergone intestinal resections. In patients with intestinal resections, neutrophil count(p=0.013), CRP(p=0.002), platelet–lymphocyte ratio(PLR, p=0.008), NLR(neutrophil–lymphocyte ratio, p=0.026), and LCR(lymphocyte–CRP ratio, p<0.001) values were significantly higher than those in the patients without any resections. Receiver operating characteristic (ROC) analysis results showed that the combination of lymphocytic count along with C-reactive protein levels (LCR) demonstrated the highest correlation with intestinal resection due to intussusception compared with other parameters in patients, with sensitivity of 0.82(0.73–0.86) and specifficity of 0.80(0.57–0.94) for the diagnosis of strangulation. Conclusion: The preoperative LCR level is a useful marker to predict the need for intestinal resection due to intestinal necrosis in patients with intussusception.

Vólvulo de ciego con lesión de colon ascendente reporte de un caso y alternativas de tratamiento

Cecal volvulus is a rare disease responsible for 1% of the cases of intestinal occlusion, whose main etiology is due to a mobile cecum. A 73-year-old male patient with a history of constipation is presented. He had a clinical picture of abdominal pain and distention, nausea, vomiting, and absence of stool or gas expulsion. A Cecal volvulus with lesion in the ascending colon was found. The surgical technique most frequently performed by surgeons for cecal volvulus is right hemicolectomy with transverse ileus anastomosis, but if the volvulus caused intestinal necrosis and the patient is hemodynamically unstable, it is safer to perform intestinal resection and ileostomy. Ascending ileus anastomosis performed at a higher level of the ascending colon is a safe alternative for the restitution of intestinal transit in patients with cecal volvulus.

Value of the ultrasound research in the diagnostic of acute strangulated small bowel obstruction

Purpose. To identify and evaluate the effectiveness of sonographic signs of intestinal ischemia in patients with strangulated small bowel obstruction.Materials and methods. For the period 2017–2019, 115 patients with SIO were treated at the N.V. Sklifosovsky Federal Research Institute of Emergency Medicine. There were 64 women (55.6%) and 51 men (44.4%). The mean age was 62 ± 15 years. In all patients, the diagnosis was verified intraoperatively. All patients underwent ultrasound examination of the abdominal cavity in B-mode with the assessment of blood flow of the intestinal wall in the mode of CDI. Patients were divided on the basis of intraoperative data into 2 groups. The first group: 63 (54.8%) patients with signs of ischemia of the strangulated loop of the intestine. The second group consisted of 21 (18.1%) patients in whom intestinal necrosis was detected. The comparison group included 31 (26.7%) patients with adhesive small bowel obstruction without intestinal strangulation.Results. The most informative signs of ischemia of the strangulated intestine of the loop are infiltrative changes of its mesentery. In the second and third groups 9 (14.3%) and 12 (57.1%) participants, respectively, showed severity of intestinal ischemia, compared with 1 participant (3.2%) in the first group. The next informative criterion is the thickening of more than 0.4 cm and edema of the intestinal wall. In the second and third groups 30 (47.6%) and 14 (66.6%), in the comparison group 4 (12.9%), akinesis of the strangulated loop and paresis of the entire small intestine also directly correlated with intestinal ischemia. The absence of differentiation of intestinal wall layers occurs in (23.8%), the absence of blood flow in the intestinal wall in the CDI mode (19%), gas inclusions in the intestinal wall (4.3%).Conclusion. The assessment of sonographic symptoms allows to diagnose the presence of ischemic changes in the intestinal wall and perform surgery before the development of necrosis in the early period. In cases of late admission of the patient to the hospital, with the onset of intestinal necrosis and the associated erased clinical picture, ultrasound allows to establish indications for surgery before the development of peritonitis.