Teenage Male with Cough and Recurrent Bruit

A general pediatrician is skilled at continuity; through longitudinal evaluation, they serve as front-line providers in the recognition and referral of unusual pathology. The majority of arteriovenous malformations (AVM) are diagnosed with history and physical examination. AVM are inherently progressive by nature; their expansion is what creates the risk of morbidity. With higher-risk vascular lesions, relative risk is important when discussing management with observation versus with invasive intervention. Size, location, and expected course of progression of the lesion help generate a timeline for action. Collaboration of physicians with diverse expertise generates optimal plan of therapy, particularly when faced with an unusual clinical finding. Genetics referral may be beneficial, as the body of literature on AVM is growing, and databases on associated syndromes are evolving. Establishing concrete follow-up is imperative to assess for recurrence of AVM or development of additional symptoms. This can be with the interventionalist or with the generalist.

Agentes Fluoretados e Cárie Radicular: Uma Revisão de Literatura / Fluoride Agents and Root Caries: A Literature Review

Resumo: A cárie radicular é uma patologia progressiva e dinâmica que ocorre na interface biofilme e cemento/dentina radicular, com maior taxa de prevalência na população idosa. O uso profissional de agentes fluoretados consiste na intervenção minimamente invasiva, capaz de prevenir e inativar as Lesões de Cárie Radicular (LCRs). Desta forma, o presente estudo objetivou identificar os diferentes agentes terapêuticos fluoretados de uso profissional que agem na inativação/paralisação da cárie radicular. Para tanto, foi realizado levantamento bibliográfico dos últimos cinco anos por meio de análise criteriosa de artigos científicos. Os idiomas foram, predominantemente o português, inglês e espanhol. Como critérios de inclusão foi considerado os trabalhos relacionados com o objetivo do presente estudo, estudos disponíveis na integra, artigos publicados entre 2016 e 2021, sendo descartados artigos que não estavam em consonância com o objetivo deste estudo, teses e dissertações. Conclui-se que o Diamino Fluoreto de Prata (DFP) é o agente fluoretado que apresentou maior eficácia na prevenção e paralização das LCRs. Contudo, sugere-se que mais estudos sejam realizados, com foco na intervenção minimamente invasiva, que tragam protocolos clínicos de atendimento adequado ao tratamento da cárie radicular Palavras-chave: Cárie; Cárie radicular; Agentes fluoretados.Abstract: Root caries is a progressive and dynamic pathology that occurs at the biofilm and cementum/root dentin interface, with a higher prevalence rate in the elderly population. The professional use of fluoridated agents is a minimally invasive intervention capable of preventing and inactivating Root Caries Lesions (CRLs). Thus, the present study aimed to identify the different fluoride therapeutic agents for professional use that act in the inactivation/paralysis of root caries. Therefore, a bibliographic survey of the last five years was performed through a careful analysis of scientific articles. The languages were predominantly Portuguese, English and Spanish. As inclusion criteria, works related to the objective of this study were considered, studies available in full, articles published between 2016 and 2021, and articles that were not in line with the objective of this study, theses and dissertations were discarded. It is concluded that Silver Diamino Fluoride (DFP) is the fluoridated agent that showed the greatest effectiveness in preventing and paralyzing CSFs. However, it is suggested that more studies be carried out, focusing on minimally invasive intervention, which bring clinical protocols for adequate care for the treatment of root caries. Keywords: Caries; Root caries; Fluoridated agents.

384 What Proportion of Pyelonephritis Admissions Under Urology Care Have Surgical Pathology

Aim To identify the proportion of pyelonephritis patients admitted with true urological pathology Method Retrospective audit Results The majority of adults admitted with diagnosis of pyelonephritis (80%) remain under urology team from 1st day of admission Of the 80% only 9% had an underlying urological pathology confirmed by imaging AND requiring invasive intervention Conclusions High rate of inappropriate admission to surgical / urological ward with subsequent pressure on beds and inevitable cancellations on some occasions Acute pyelonephritis should not be routinely admitted under urology unless there is clear evidence of underlying obstructing pathology or no obvious improvement on antibiotics Consider imaging in terms of US/CT KUB in first instance before making any referral to urology

245 A RETROSPECTIVE ANALYSIS OF ADVERSE EVENTS OF PERORAL ENDOSCOPIC MYOTOMY

Peroral endoscopic myotomy (POEM) has rapidly vindicated its position within the spectrum of achalasia treatment methods due to its excellent efficacy and safety. Nevertheless, POEM remains an invasive intervention which still carries risk of potential complications. The aim of our detailed analysis was to assess the perioperative and early postoperative adverse events in patients undergoing POEM at our institution. Methods We retrospectively evaluated the prospectively collected data from all consecutive patients who underwent POEM 12/2012–5/2018 at our institution and searched for periprocedural complications. Surgical classification Clavien Dindo (C-D) was used to assess the severity of adverse events. Results A total of 243 POEM procedures were performed. 73 procedures (30.0%) passed uneventfully while in 170 procedures (70.0%), 208 adverse events occurred. Minor AEs (C-D I,II) were as follows: allergic reaction to antibiotics (2/243; 0.8%), anaesthesia-related complications (14; 5.8%), pain requiring analgesics (158; 65%), fever (20; 8.2%), pneumonia (3; 1.2%) and irreversible loss of taste and smell (1; 0.4%). Major adverse events (CD III and more) included: post-POEM leak from mucosal incision requiring endoscopic clipping (5; 2.0%), pneumothorax (2; 0.8%), pleural effusion (1; 0.4%), scrotum emphysema (1; 0.4%) and death due to sudden cardiac arrest (1; 0.4%). Conclusion Minor POEM-related adverse events are rather common. Although being rare, severe complications, and even fatal, may still occur. Overall, POEM can be considered a safe procedure.

749 Unexpected benefits of pandemic guidelines for the management of epistaxis

Aim The Royal Victoria Hospital adopted ENT UK’s pandemic guidelines for the management of epistaxis. We aimed to reduce ENT referrals, in-patient admissions and staff exposure to COVID-19 whilst maintaining patient safety. This involved collaboration with ED to promote the use of absorbable packs and pharmacological alternatives over rhinoscopy & rigid endoscopy with cautery +/- non-absorbable packs. Method Data was collected on patients presenting with epistaxis over a six-week period beginning March 2020 and the same period in 2019. Key factors recorded were number of presentations, ENT referrals, admissions, and their durations, along with management and outcomes. ENT provided training to ED staff and produced video resources for the "My ED" app. Feedback from ED and patient data was gathered to improve training and assess effectiveness. Results Pre-pandemic, 48% of ED epistaxis presentations were referred to ENT vs. 28% following the guidelines introduction. In 2019 49% of referrals were admitted vs. 42% in 2020. The average in-patient stay was reduced from four nights to one. Re-admission rate remained similar from 22% in 2019 to 20% in 2020. These results were achieved following repeated improvements to the training sessions. Conclusions The ENT UK guidelines, when supplemented with ED collaboration, are effective at reducing ENT referrals and admissions. In addition to reducing COVID-19 exposure, the guidelines offered an improved patient experience (less invasive intervention, reduced/removed in-patient stay) with no loss of efficacy. This, combined with a reduced treatment cost of ∼£2,000 per in-patient, suggests the guidelines have long-term value out-with a pandemic setting.

Early versus differed arterial catheterisation in critically ill patients with acute circulatory failure: a multicentre, open-label, pragmatic, randomised, non-inferiority controlled trial: the EVERDAC protocol

IntroductionThe use of peripheral indwelling arterial catheter for haemodynamic monitoring is widespread in the intensive care unit and is recommended in patients with shock. However, there is no evidence that the arterial catheter could improve patient’s outcome, whereas the burden of morbidity generated is significant (pain, thrombosis, infections). We hypothesise that patients with shock may be managed without an arterial catheter.Methods and analysisThe EVERDAC study is an investigator-initiated, pragmatic, multicentre, randomised, controlled, open-label, non-inferiority clinical trial, comparing a less invasive intervention (ie, no arterial catheter insertion until felt absolutely needed, according to predefined safety criteria) or usual care (ie, systematic arterial catheter insertion in the early hours of shock). 1010 patients will be randomised with a 1:1 ratio in two groups according to the strategy. The primary outcome is all-cause mortality by 28 days after inclusion. A health economic analysis will be carried out.Ethics and disseminationThe study has been approved by the Ethics Committee (Comité de Protection des Personnes Île de France V, registration number 61606 CAT 2, 19 july 2018) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT03680963.

Observed risk of recurrent bleeding and thromboembolic disease in COVID-19 patients with gastrointestinal bleeding

Background and study aim COVID-19 patients are at increased risk for venous thromboembolism (VTE) requiring the use of anticoagulation. Gastrointestinal bleeding (GIB) is increasingly being reported, complicating the decision to initiate or resume anticoagulation as providers balance the risk of thrombotic disease with the risk of bleeding. Our study aimed to assess rebleeding rates in COVID-19 patients with GIB and determine whether endoscopy reduces these rebleeding events. We also report 30-day VTE and mortality rates. Methods This was a retrospective study evaluating 56 COVID-19 patients with GIB for the following outcomes: 30-day rebleeding rate, 30-day VTE rate, effects of endoscopic intervention on the rate of rebleeding, and 30-day mortality. Results The overall rates of VTE and rebleeding events were 27 % and 41 %, respectively. Rebleeding rates in patients managed conservatively was 42 % compared with 40 % in the endoscopy group. Overall, 87 % of those who underwent invasive intervention resumed anticoagulation vs. 55 % of those managed medically (P = 0.02). The all-cause 30-day mortality and GIB-related deaths were 32 % and 9 %, respectively. Mortality rates between the endoscopic and conservative management groups were not statistically different (25 % vs. 39 %; P = 0.30). Conclusions Although rebleeding rates were similar between the endoscopic and conservative management groups, patients who underwent intervention were more likely to restart anticoagulation. While endoscopy appeared to limit the duration that anticoagulation was withheld, larger studies are needed to further characterize its direct effect on mortality outcomes in these complex patients.

Management of the penetrating atherosclerotic ulcer in the descending thoracic aorta

Penetrating atherosclerotic ulcers present with an insidious onset with a reported mortality of 9%, varying across populations. With vast arrays of risk factors and potentially ominous complications, it is vital to efficiently provide optimum strategies for management. There exists controversy in the literature regarding management, especially for Type B penetrating atherosclerotic ulcers; the decision-making framework encompasses numerous factors in considerations for medical management versus invasive intervention and choice of endovascular versus open repair in the latter. The concomitant presence of intramural haematoma adds further complexity to the already intricate decision-making for management. We performed searches through PubMed and SCOPUS analysing studies reporting outcomes for management strategies for penetrating atherosclerotic ulcers treatment, focusing on Type B, further seeking to analyse studies reporting their experiences of PAU patients with concomitant intramural haematoma. Our review highlights the ambiguity and controversy existing in the literature, comprising studies burdened by their inherent hindering limitations of their single-centre retrospective experiences. Endovascular therapy has come to the forefront of penetrating atherosclerotic ulcers management, often considered first line therapy. In the case of penetrating atherosclerotic ulcers alongside intramural haematoma, there have been reports of potential hybrid surgical approaches to management. Studies further show misdiagnosis of penetrating atherosclerotic ulcers in earlier data sets further complicates management. However, it is clear we must progress on the journey towards precision medicine, allowing delivery of optimum care to our patients.

The Ultrasonic Electrical Stimulation Treating Recent Pain after Minimally Invasive Intervention with Disc Degenerative Diseases

Objective:To explore the analgesic effect of ultrasonic electrical stimulation for recent pain after minimally invasive interventional therapy for intervertebral disc degenerative diseases (DDD). Methods:From January to August 2019, 130 patients with DDD who were treated by minimally invasive intervention of intervertebral disc, and then were randomly divided into electrical stimulation group and conservative treatment group. After minimally invasive intervention, the electrical stimulation group was treated by ultrasonic electrical stimulation once a day for 7 days. The conservative treatment group was treated with conventional acupuncture and massage once a day for 3 days.The pain degree of before treatment and 3 days, 7 days and 1 month(m) after treatment were evaluated by pain numberical rating scale (NRS), the curative effect of 1 m post-cure was evaluated by NRS weighting method. Results:There was no significant difference of NRS score between the two groups before treatment (P > 0.05). NRS of electrical stimulation group were significant lower than those in conservative treatment group, which was evaluated at several time point for 3 days, 7 days and one month after treatment (P < 0.001). The curative effect of electrical stimulation group on one month after interventional treatment was significantly higher than that of conservative treatment group (P < 0.001). Conclusion:The therapeutic effect of ultrasonic electrical stimulation is better than that of traditional acupuncture and massage for recent pain after minimally invasive interventional therapy with DDD, it is worthy to popularize in clinical treatment. Key words: After interventional therapy with DDD; The recent pain; ultrasonic electrical stimulation

Environmental enrichment mitigates the long-lasting sequelae of perinatal fentanyl exposure

The opioid epidemic is a rapidly evolving societal issue that stems from the abuse of prescription and illicit opioids, including increasing use of synthetic opioids like fentanyl. Fentanyl use among women has increased substantially in the last decade, leading to a 40-fold increase in the number of perinatally-exposed infants. This exposure can result in neuropsychiatric abnormalities that persist into adolescence and, in some cases, adulthood. We previously developed a preclinical model to establish the consequences of perinatal fentanyl exposure and identified a pattern of synaptic pathophysiology that involves lasting impairments in primary somatosensory (S1) circuit function and behavior. Here, we ask if these long-lasting effects can be restored by a non-invasive intervention. We demonstrate that developmental exposure to environmental enrichment ameliorates many of fentanyl's deleterious behavioral effects, including hyperactivity, enhanced sensitivity to anxiogenic environments, and sensory maladaptation. As an extension of our past work, we found that perinatal fentanyl alters the frequency of miniature excitatory postsynaptic currents and impairs long-term potentiation in S1 layer 2/3 neurons. These deficits in synaptic function were restored by environmental enrichment. Environmental enrichment also affected neurons in control mice, reducing long-term potentiation and depression, and increasing frequency of miniature excitatory postsynaptic currents. These results demonstrate that the lasting somatosensory-related effects of fentanyl can be ameliorated with a non-invasive intervention introduced during early development. These findings can inform ongoing efforts to develop actionable steps toward mitigating the consequences of opioid abuse among pregnant women.