Modified laparoscopic transthoracic hepatectomy for upper liver segments: Technique, indications, and early outcomes.

Transthoracic access emerges as an innovative approach to reach lesions in the upper hepatic segments, especially in patients with prior surgeries. This study evaluates transthoracic access for these resections through a retrospective single-center analysis of demographic data, surgical techniques, and postoperative outcomes of 353 liver surgeries, revealing promising results with minimal complications. Transthoracic access and pneumoperitoneum establishment via the transthoracic route, combined with intercostal trocar insertion, offer a viable alternative for minimally invasive liver surgeries.

Influence of biliary and vascular resection types on morbidity in hepatectomies with vascular involvement.

INTRODUCTION: Hepatectomies associated with vascular resections pose a technical challenge for surgeons, involving multiple reconstruction techniques. Moreover, adding clinical and surgical risks in the postoperative setting of these complex procedures are mainly due to prolonged surgical periods and potential complications inherent to vascular manipulation. Leveraging the expertise of a Cancer Center, we propose an institutional assessment utilizing the case series from A. C. Camargo Cancer Center in hepatectomies associated with vascular resection, evaluating postoperative complications and outcomes while highlighting clinical, laboratory, pathological, and surgical factors that may influence results. OBJECTIVE: To assess mortality and morbidity associated with hepatectomies involving vascular resection. MATERIALS AND METHODS: From a prospective database, a study was performed evaluating postoperative survival and morbidity using scoring systems such as Clavien-Dindo through a cohort analysis. RESULTS: From a total of 1021 liver resections for a period of 10 years, 31 cases were evaluated from a unique cancer center in Brazil! Factors such as the performance of major hepatectomies, the need for blood transfusion, and the administration of neoadjuvant or adjuvant systemic therapy did not appear to influence the outcome of morbidity or mortality. However, the resection of the associated bile duct and the type of vascular resection seemed to influence morbidity outcomes with statistical significance (p = 0.006+ …). CONCLUSION: Hepatectomies associated with vascular resections are safe in selected cases and when performed in referral centers. Factors such as associated bile duct resection and type of vascular resection should be considered for procedure indication.

Dense tumor-infiltrating lymphocytes (TILs) in liver metastasis from colorectal cancer are related to improved overall survival.

BACKGROUND AND OBJECTIVES: Tumor-infiltrating lymphocytes (TILs) represent a host-tumor interaction, frequently signifying an augmented immunological response. Nonetheless, implications with survival outcomes in patients with colorectal carcinoma liver metastasis (CRLM) warrant rigorous validation. The objective was to demonstrate the association between TILs and survival in patients with CRLM. METHOD: In a retrospective evaluation conducted in a single institution, we assessed all patients who underwent hepatectomy due to CRLM between 2014 and 2018. Comprehensive medical documentation reviews were executed. TILs were assessed by a liver pathologist, blinded to the clinical information, in all surgical slides. RESULTS: This retrospective cohort included 112 patients. Median overall survival (OS) was 58 months and disease-free survival (DFS) was 12 months for the entire cohort. Comparison between groups showed a median OS of 81 months in the dense TILs group and 40 months in the weak/absent group (p = 0.001), and DFS was 14 months versus 9 months (p = 0.041). Multivariable analysis showed that TILs were an independent predictor of OS (HR 1.95; p = 0.031). CONCLUSIONS: Dense TILs are a pivotal prognostic indicator, correlating with enhanced OS. Including TILs information in histopathological evaluations should refine the clinical decision-making process for this group of patients.

Current clinical practice in the management of Brazilian patients with potentially resectable pancreatic ductal adenocarcinoma (PDAC).

BACKGROUND AND OBJECTIVES: We aimed to describe the routine clinical practice of physicians involved in the treatment of patients with localized pancreatic ductal adenocarcinoma (PDAC) in Brazil. METHODS: Physicians were invited through email and text messages to participate in an electronic survey sponsored by the Brazilian Gastrointestinal Tumor Group (GTG) and the Brazilian Society of Surgical Oncology (SBCO). We evaluated the relationship between variable categories numerically with false discovery rate-adjusted Fisher's exact test p values and graphically with Multiple Correspondence Analysis. RESULTS: Overall, 255 physicians answered the survey. Most (52.5%) were medical oncologists, treated patients predominantly in the private setting (71.0%), and had access to multidisciplinary tumor boards (MTDTB; 76.1%). Medical oncologists were more likely to describe neoadjuvant therapy as beneficial in the resectable setting and surgeons in the borderline resectable setting. Most physicians would use information on risk factors for early recurrence, frailty, and type of surgery to decide treatment strategy. Doctors working predominantly in public institutions were less likely to have access to MTDTB and to consider FOLFIRINOX the most adequate regimen in the neoadjuvant setting. CONCLUSIONS: Considerable differences exist in the management of localized PDAC, some of them possibly explained by the medical specialty, but also by the funding source of health care.

Experiences of parents of children with hypoplastic left heart syndrome during their treatment: a qualitative study.

AIM: To investigate the opinion and personal experience of parents of children born with Hypoplastic Left Heart Syndrome and what advice they would give to other parents who have to decide between treatment options. METHODS: We conducted a qualitative, descriptive and retrospective study by means of a survey directed to parents of children born with Hypoplastic Left Heart Syndrome in a tertiary hospital in Buenos Aires (Argentina). Their answers and data regarding medical procedures were analysed. RESULTS: Parents of thirteen out of sixteen patients with Hypoplastic Left Heart Syndrome were surveyed. Norwood surgery had been performed in all the patients, many had received other procedures, and five had died. In relation to the decision-making process, sixty-one percent of parents would recommend other parents to remain at peace after having done everything possible and 54% would suggest to not feel guilt despite the final result. None of the parents would recommend rejecting surgical treatment and choosing comfort care. CONCLUSION: The majority of parents of children with Hypoplastic Left Heart Syndrome would recommend continuing with the therapeutic effort in order to feel at peace and reduce feelings of guilt.

Symptomatic Recurrence and Survival Outcomes After Curative Treatment of Gastric Cancer: Does Intensive Follow-up Evaluation Improve Survival?

BACKGROUND: Intensive surveillance after treatment of gastric cancer patients with curative intent may lead to an earlier diagnosis of disease recurrence, but its impact on survival is uncertain. This study aimed to evaluate whether early diagnosis of disease recurrence among asymptomatic patients was associated with long-term survival. METHODS: This retrospective study analyzed patients with stages 1 to 3C gastric adenocarcinoma treated between 1999 and 2018. All recurrence events were classified as symptomatic or asymptomatic (detected by follow-up tests), and their clinicopathologic characteristics, patterns of recurrence, and survival were analyzed. RESULTS: The cohort consisted of 669 patients treated with a total gastrectomy in 48.6% and a D2-lymphadenectomy in 88.8% of the cases. Most of the tumors were pT3-4 (46.5%), with 45.5% involving lymph node metastases and 42.3% manifesting a diffuse histology. During a median follow-up period of 80.1 months (95% confidence interval [CI], 75.3-84.8 months), 166 patients had recurrences (24.8%), 65.7% of which were symptomatic. The peritoneum was the main site of recurrence (37.2%), and peritoneal recurrence was associated with worse overall survival (OS) (hazard ratio, 1.69; 95%CI, 1.2-2.37). The median disease-free, post-recurrence survival, and OS periods in the asymptomatic and symptomatic groups were respectively 13.4 versus 17.2 months (p = 0.04), 11.9 versus 4.7 months (p < 0.001), and 29.9 versus 26.4 months (p = 0.21). When OS was analyzed among the patients with non-peritoneal recurrence, no difference was observed between the two groups (31.3 vs 31.1 months; p = 0.46). CONCLUSION: Early diagnosis of asymptomatic disease recurrence did not affect the OS of the gastric cancer patients treated with curative intent. The use of intensive surveillance strategies in this scenario still requires further evidence.

Patterns of disease relapse and posttreatment follow-up of patients with resected pancreatic adenocarcinoma: A single-center analysis.

BACKGROUND AND OBJECTIVES: To describe the patterns of disease relapse and follow-up of patients with resected pancreatic adenocarcinoma. Additionally, we looked at patients' characteristics at relapse and survival. METHODS: We included patients with potentially resectable pancreatic adenocarcinoma diagnosed from 2008 to 2018 who were submitted to resection with clear macroscopic margins and started posttreatment surveillance. RESULTS: The study population consists of 73 patients. The median interval between imaging studies was 3.2 months during the first 2 years of follow-up and 5.1 months thereafter. Forty-eight patients (65.8%) experienced disease relapse. The most frequent single site of relapse was locoregional (N = 21; 43.8%). At relapse, 31 patients (64.6%) were symptomatic and forty-two patients (87.6%) had Eastern Cooperative Oncology Group performance status 0 or 1. Most patients were able to undergo additional anticancer therapy (N = 41; 85.4%). Patients with asymptomatic relapses experienced longer median postrelapse survival (25.4 vs. 11.3 months; p = 0.015). CONCLUSIONS: A follow-up protocol that included imaging studies every 3 months in the first 2 years and every 6 months thereafter is able to diagnose disease relapse when patients have adequate performance status and are still able to undergo additional anticancer treatment.

Surgery or active surveillance for pNETs < 2 cm: Preliminary results from a single center Brazilian cohort.

BACKGROUND AND OBJECTIVES: Incidence of pancreatic neuroendocrine tumors (pNETS) seems to be rising over the years, with many cases incidentally diagnosed. Surgery and active surveillance are current treatment modalities for small pNETS. We review our institutional series and compare outcomes for small asymptomatic and nonfunctioning tumors. METHODS: This retrospective cohort study included patients with 2 cm or less and well differentiated pNETS at a single Brazilian Cancer Center. From 2002 to 2020, patients received active surveillance or surgery as a treatment strategy. Short and long-term results were compared. RESULTS: Sixty-four patients were included, 41 in surgical strategy and 23 in the active surveillance approach. Baseline group characteristics were comparable. More patients on active surveillance underwent abdominal magnetic resonance imaging (MRI) and had tumors located in the pancreatic head (41% vs. 17%, p = 0.038). Minimally invasive procedure was chosen in 80.1% of the surgical patients. No patient died after surgery. Median follow-up period was 38.6 and 46.4 months for active surveillance and surgery cohorts, respectively. No difference in disease progression rate was observed. CONCLUSION: Both approaches seem to be safe for small pNETs. Long-term outcome and quality of life should be considered when discussing such options with patients.

PD-L1 expression in gastric and gastroesophageal junction cancer patients treated with perioperative chemotherapy.

BACKGROUND AND OBJECTIVES: The incidence, predictive, and prognostic impact of programmed cell death (PD-L1) expression in gastric (GC) and gastroesophageal junction tumors (GEJC) treated with perioperative chemotherapy is poorly understood. We aimed to assess PD-L1 expression by immunohistochemistry (IHC) in both pre and posttreatment specimens evaluating its impact on pathological response and survival outcomes. METHODS: Retrospective cohort of patients with GC and GEJ tumors treated in a single western cancer center between 2007 and 2017. PD-L1 expression was assessed by IHC before and after neoadjuvant chemotherapy, in surgical samples, and reported as combined positive score (CPS). CPS > 1% was tested for its association with pathological response and overall survival (OS). RESULTS: We were able to assess PD-L1 expression in at least one tissue sample from 155 subjects. PD-L1 positivity rate was 20%. In 74 paired samples, a 21% discordance between PD-L1 expression in biopsy sample and surgical specimen was observed. With a median follow-up period of 60.3 months, 5-years disease-free survival was 60.5% with a median OS not reached. PD-L1 expression was neither associated with pathological response or survival outcomes. CONCLUSIONS: PD-L1 expression in the setting of locally advanced GC tumors was relatively low and can vary considering the tissue sample analyzed. This expression had no association with survival or pathological response in this population.

Pediatric KT in children up to 15 kg: A single-center experience.

BACKGROUND: KT is the preferred treatment for ESRD in pediatrics. However, it may be challenging in those weighing ≤15 kg with potential complications that impact on morbidity and graft loss. METHODS: This retrospective review reports our experience in KT in children, weighing ≤15 kg, and the strategies to reduce morbidity and mortality. RESULTS: All patients were on RRT prior to KT. Patients reached ESRD mainly due to urologic malformations (54.54%). LD was performed in 82% of patients. The recipient's median age was 2.83 years, and median weight 12.280 kg. Male sex was predominant (73%). All patients required transfusions of PRBCs. There was a high requirement for ventilated support in patients post-KT with no relation to weight, amount of resuscitation used intra-operatively or ml/kg of PRBCs. One patient presented with stenosis of the native renal artery. No patients presented DGF, graft thrombosis, or surgical complications. No association was found between cold ischemia and eGFR at 1 year (p = .12). In univariate analysis, eGFR at 1 year is related to AR. eGFR at 3 years is related to the number of UTI. Median follow-up was 1363 days. Patient and graft survival were 100%. CONCLUSIONS: KT in children ≤15 kg can be challenging and requires a meticulous perioperative management and surgical expertise. Patient and graft survival are excellent with low rate of complications.

Short-term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center.

INTRODUCTION: Pancreatic malignant tumors are resectable at diagnosis in only 15% to 20% of cases and invasion of vascular structures is commonly present. Therefore, extended resections are needed for adequate local control and negative margins. However, morbidity and mortality associated with these enlarged resections are limiting factors. The aim of this study was to correlate demographic and technical aspects that influenced early and late outcomes. MATERIALS AND METHODS: Between October 2007 and May 2019, 523 pancreatic surgeries were performed, of which 72 required vascular resections. Clinical and histopathological data, surgical techniques, and perioperative parameters were analyzed in a prospectively collected database. RESULTS: Of the 72 cases of vascular resection, 31 were male and 41 females with a mean age of 60.9 years (34-81). The most commonly affected vascular structure was the portal vein (in 40.3%). Free margins were obtained in 77.8% of cases. Postoperative mortality rate at 60 days was 13.9%. American Society of Anesthesiologists (ASA) and age were the most important predictors of major complications. CONCLUSION: Extended resections with vascular involvement in pancreatic surgeries are feasible and safe; furthermore, patient selection plays are key. ASA and age were the most important factors in the decision-making process for extended resections.

Predictors of long-term survival in patients with hepatic resection of colorectal metastases: Analysis of a Brazilian Cancer Center Cohort.

BACKGROUND: Hepatic metastases are a major cause of death in patients with colorectal cancer. A comprehensive assessment of the prognostic factors associated with long-term survival could improve patient selection for surgical approaches and decrease morbidity and futile locoregional treatments. METHODS: We performed a retrospective analysis of patients who underwent hepatectomy for colorectal liver metastases at a single center from 2000 to 2012. RESULTS: To identify factors associated with 5- and 10-year overall (OS) and disease-free survival (DFS), we analyzed 280 patients and 150 patients in the 5- and 10-year cohorts, respectively. Only seven relapses occurred after 5 years of follow-up, and no relapses occurred after 10 years. Multivariable analysis indicated that bilobar disease and extra-hepatic disease before hepatectomy were independent 5- and 10-year predictors of OS, and major postoperative complications predicted OS in the 5-year survival cohort only. Our analysis indicated that prognostic factors associated with DFS included some confounders and was therefore inconclusive. CONCLUSIONS: Taken together, our results suggest that the predictors of 5- and 10-year OS rates of colorectal cancer patients with hepatic metastases are similar, differing only by postoperative complications that influenced exclusively 5-year survival. Since no relapse occurred 10 years after hepatic resection, oncological remission is likely.

Does hipec improve outcomes in gastric cancer patients treated with perioperative chemotherapy and radical surgery? A propensity-score matched analysis.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with improved survival when compared with surgery alone for non-metastatic gastric cancer patients in randomized trials and meta-analyses. However, little evidence is available regarding the use of HIPEC in nonmetastatic patients who are treated with perioperative chemotherapy and radical surgery. The aim of this study was to investigate the putative survival benefit of HIPEC in the subgroup of gastric cancer patients treated with perioperative chemotherapy and surgery. PATIENTS AND METHODS: This was a retrospective cohort study that included gastroesophageal junction and gastric cancer patients who were treated with perioperative chemotherapy and curative resection in a single cancer center in the period between 2006 and 2017. In this time period, younger patients with diffuse-type tumors and serosa invasion or positive lymph node disease were often offered an adjuvant HIPEC protocol. This study compared the survival outcomes of these patients to the ones of those who received only perioperative chemotherapy and resection. A 2:1 propensity-score matched analysis for the two groups was also performed, and variables used were postchemotherapy T (ypT) and N (ypN) stages, histology and tumor site. RESULTS: The study population comprised 269 subjects, 241 treated with chemotherapy and surgery and 28 who also received HIPEC. The mean age was 59 years old (standard deviation: 12.2) and 60% of all individuals were male. A total gastrectomy was performed in 137 patients and a distal resection in 132, with a D2-lymphadenectomy in 97.4% of the sample. Overall 60-day morbidity and mortality rates were 35.3% and 3.3%, respectively. In the HIPEC group, patients were younger, and more frequently had American Society of Anesthesiologists (ASA) 1 to 2 classification, tumors located in the gastric body, had diffuse histology, and ypN+ disease. Overall survival (OS; 5 years) results in the HIPEC and no HIPEC group were 59.5% vs 68.7% (P = .453), and disease-free survival (DFS) ones were 49.5% and 65.8% (P = .060), respectively. In the multivariable Cox regression model, ypT and ypN were independent overall and DFS predictors; also, ASA 3 to 4 classification and diffuse histology were associated with worse OS. In the matched analysis, HIPEC did not improve either overall (53.5% vs 59.5%; P = .517) or DFS (50.0% vs 49.5%; P = .993). CONCLUSION: Treatment with HIPEC in patients who received perioperative chemotherapy and a D2-resection did not improve survival outcomes. Both ypT and ypN stages remained as the most important survival predictors in this cohort.

[Reduction of prescription error and its adverse effects in the pediatric intensive care area]. / Reducción del error de prescripción y de sus efectos adversos en el área pediátrica de cuidados intensivos.

INTRODUCTION: Prescription is the node of medication management and use that most frequently presents medication errors, according to various studies. This study aims to analyze prescriptions before and after the incorporation of a multidisciplinary round in the pediatric intensive care area and its implication in the occurrence of adverse drug events. METHODS: This is an uncontrolled before and after study. RESULTS: 100 patients were studied before and 100 after, range 1-17 years, mean age: 6.4 SD: 8.7. 55.5% (n = 111) were men. A prescription error was detected before the intervention of 12% (n = 12) and after 0% of the intervention, 0%, p = 0.001. A total of 45 adverse events were detected, that is, 45 adverse events per 100 admissions and 38, that is, 38 events per 100 admissions, before and after the intervention respectively (p > 0.05). CONCLUSION: The intervention was useful to reduce prescription error in this sample of patients.

Introducción: La prescripción es el nodo del manejo y uso de medicamentos que con mayor frecuencia presenta errores de medicación, según diversos estudios. Este estudio tiene como objetivo analizar las prescripciones antes y después de la incorporación de una ronda multidisciplinar en el área de cuidados intensivos pediátricos y su implicación en la ocurrencia de eventos adversos por medicamentos. Métodos: Se trata de un estudio antes y después, no controlado. Resultados: Se estudiaron 100 pacientes antes y 100 después, rango 1-17 años, edad media: 6.4 DE: 8.7. El 55.5% (n = 111) eran varones. Se detectó un error de prescripción antes de la intervención del 12% (n = 12) y después de intervención, del 0%, p = 0.001. Se detectó un total de 45 eventos adversos por 100 ingresos y 38 eventos por 100 ingresos, antes y después de la intervención respectivamente (p > 0.05). Conclusión: La intervención fue útil para disminuir el error de prescripción en esta muestra de pacientes.

Unplanned transfer of pediatric patients from the general ward to the intensive care unit. / Traslado no programado de pacientes pediátricos desde una sala de internación general a una unidad de cuidados intensivos.

Introduction. During hospitalization, patients may develop significant clinical deterioration and require unplanned admission to the pediatric intensive care unit (PICU). This may result in increased morbidity and mortality. These events are often preceded by a deterioration phase that may go unnoticed. Objective. To determine the frequency, analyze the causes, and describe the clinical characteristics and outcomes of unplanned transfers of hospitalized pediatric patients from the general pediatric ward (GPW) to the PICU, and analyze the differences between urgent and emergent transfers. Population and methods. Prospective, descriptive study; all unplanned transfers from the GPW to the PICU occurring between January 1st , 2014 and December 31st, 2019 were analyzed. Results. There were 212 unplanned transfers (21 transfers per 1000 admissions). An associated comorbidity was present in 76% of transferred patients -being cancer the most frequent one (36%)- and they had been hospitalized for more than 24 hours in the GPW. The most frequent causes of transfer were respiratory distress (43%), sepsis (20%), and neurological/neurosurgical complications (20%). The overall mortality rate was 8.96% (19 patients). Conclusions. The analysis of unplanned transfers is a critical component in the assessment of the quality of care and patient safety of an area, and should be an indicator integrated into the control panel. The interpretation of unplanned transfers as a preventable event is a key paradigm shift.

Introducción. Durante la internación, los pacientes pueden presentar un deterioro clínico significativo y requerir el ingreso no programado a la unidad de cuidados intensivos pediátricos (UCIP). Esto puede conllevar un aumento de la morbilidad y la mortalidad. Frecuentemente, estos eventos están precedidos por una fase de deterioro que podría pasar desapercibida. Objetivo. Determinar la frecuencia, analizar las causas, describir las características clínicas y los resultados de los traslados no programados en pacientes pediátricos hospitalizados, desde el área de internación general pediátrica (IGP) a la UCIP, y analizar las diferencias entre traslados urgentes y emergentes. Población y métodos. Estudio descriptivo prospectivo; se analizaron todos los traslados no programados desde IGP a la UCIP ocurridos entre el 1 de enero de 2014 y el 31 de diciembre 2019. Resultados. Se constataron 212 traslados no programados (21 traslados cada 1000 ingresos). El 76 % de los pacientes trasladados presentaban una comorbilidad asociada ­la más frecuente fue la patología oncológica (36 %)­ y llevaban más de 24 horas internados en IGP. Las causas más frecuentes de traslado fueron dificultad respiratoria (43 %), sepsis (20 %) y complicaciones neurológicas/neuroquirúrgicas (20 %). La tasa de mortalidad global fue del 8,96 % (19 pacientes). Conclusiones. El análisis de los traslados no programados es un elemento esencial en la evaluación de la calidad de atención y seguridad del paciente de un área, y debe constituir un indicador integrado al tablero de control. La interpretación de los traslados no programados como un evento prevenible constituye un cambio de paradigma clave.

Development and pilot testing of PROACTIVE: A pediatric onco-critical care capacity and quality assessment tool for resource-limited settings.

BACKGROUND: Nearly 90% children with cancer reside in low- and middle-income countries, which face multiple challenges delivering high-quality pediatric onco-critical care (POCC). We recently identified POCC quality and capacity indicators for PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), a tool that evaluates strengths and limitations in POCC services. This study describes pilot testing of PROACTIVE, development of center-specific reports, and identification of common POCC challenges. METHODS: The original 119 consensus-derived PROACTIVE indicators were converted into 182 questions divided between 2 electronic surveys for intensivists and oncologists managing critically ill pediatric cancer patients. Alpha-testing was conducted to confirm face-validity with four pediatric intensivists. Eleven centers representing diverse geographic regions, income levels, and POCC services conducted beta-testing to evaluate usability, feasibility, and applicability of PROACTIVE. Centers' responses were scored and indicators with mean scores ≤75% in availability/performance were classified as common POCC challenges. RESULTS: Alpha-testing ensured face-validity and beta-testing demonstrated feasibility and usability of PROACTIVE (October 2020-June 2021). Twenty-two surveys (response rate 99.4%) were used to develop center-specific reports. Adjustments to PROACTIVE were made based on focus group feedback and surveys, resulting in 200 questions. Aggregated data across centers identified common POCC challenges: (1) lack of pediatric intensivists, (2) absence of abstinence and withdrawal symptoms monitoring, (3) shortage of supportive care resources, and (4) limited POCC training for physicians and nurses. CONCLUSIONS: PROACTIVE is a feasible and contextually appropriate tool to help clinicians and organizations identify challenges in POCC services across a wide range of resource-levels. Widespread use of PROACTIVE can help prioritize and develop tailored interventions to strengthen POCC services and outcomes globally.

High mortality in patients with influenza A pH1N1 2009 admitted to a pediatric intensive care unit: a predictive model of mortality.

OBJECTIVE: To describe the clinical characteristics and outcome of patients admitted to pediatric intensive care with influenza A (pH1N1) 2009 in Argentina. DESIGN: Retrospective observational study. SETTING: Thirteen pediatric intensive care units in Argentina. SUBJECTS: One hundred and forty-two patients with confirmed or suspected influenza A (H1N1). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included 142 critically ill patients. The median age was 19 months (range, 2-110 months) with 39% of the patients <24 months of age. Ninety-nine patients (70%) had an underlying disease. Influenza A (pH1N1) 2009 infection was confirmed in 90 patients and the remaining 52 had a positive direct immunofluorescence assay for influenza A. The median length of stay in the pediatric intensive care unit was 12 days (range, 2-52 days). One hundred eighteen patients (83%) received invasive mechanical ventilation and 19 patients were treated with noninvasive ventilation; however, seven of the patients receiving noninvasive ventilation later needed mechanical ventilation. Sixty-eight patients died (47%) with the most frequent cause refractory hypoxemia. Multivariate logistic regression analysis showed that age <24 months (odds ratio, 2.87; 2.35-3.93), asthma (odds ratio, 1.34; 1.20-2.91), and respiratory coinfection with respiratory syncytial virus (odds ratio, 2.92; 1.20-4.10) were associated with higher mortality. As expected, mechanical ventilation and treatment with inotropes were also associated with increased mortality. CONCLUSIONS: The mortality of children admitted to the pediatric intensive care unit with 2009 pH1N1 influenza was high (47%) in our population. Age <24 months, asthma, respiratory coinfection, need of mechanical ventilation, and treatment with inotropes were predictors of poorer outcome.

Exploratory content analysis of direct-to-consumer pet genomics: What is being marketed and what are consumers saying?

Mars Petcare introduced the first direct-to-consumer domestic dog genetic test in 2009 and Basepaws introduced the first direct-to-consumer cat genetic test in 2016. Social science research has evaluated numerous aspects of the human direct-to-consumer market, yet no such exploration has evaluated the occurrence of pet owners pursuing pet genetic tests. Using a mixed methods approach, we conducted an exploratory content analysis of direct-to-consumer pet genetic company webpages and consumer reviews shared on Amazon. Initial data reviews indicated some companies may be key industry players, relative to others. Our results present content frequency for each group (key industry players, all other companies), though the primary themes for each remained the same. Analysis showed genetic companies are primarily sharing product and purchasing information, along with trustworthiness to establish the merit of the company and their products. Companies also used statements directed towards pet owners that are suggestive of both pets and "pet parents" benefiting from the test results. The primary themes identified in consumer reviews involved consumers sharing their perception about the tests (e.g., accuracy), what aspects of the test results they focused on (e.g., breed information), and experiences with using the test (e.g., ease of use). Amazon reviews were primarily positive, though the companies with smaller review numbers had higher percentages of negative and ambiguous sentiments. Of interest, reviews most often indicated tests were being used to determine a pet's breed identity, while companies most frequently promoted the health advantages of using their products. Reviews revealed some consumers respond to tests by sharing their pet's results with someone or by altering their pet's care. Considering these results in addition to the growing popularity of this industry and the advancements of genomic technology, further research is needed to determine the role pet genetic testing may have in society and on human-animal relationships.

Association of Cancer Diagnosis and Therapeutic Stage With Mortality in Pediatric Patients With COVID-19, Prospective Multicenter Cohort Study From Latin America.

Background: Children with cancer are at risk of critical disease and mortality from COVID-19 infection. In this study, we describe the clinical characteristics of pediatric patients with cancer and COVID-19 from multiple Latin American centers and risk factors associated with mortality in this population. Methods: This study is a multicenter, prospective cohort study conducted at 12 hospitals from 6 Latin American countries (Argentina, Bolivia, Colombia, Ecuador, Honduras and Peru) from April to November 2021. Patients younger than 14 years of age that had an oncological diagnosis and COVID-19 or multisystemic inflammatory syndrome in children (MIS-C) who were treated in the inpatient setting were included. The primary exposure was the diagnosis and treatment status, and the primary outcome was mortality. We defined "new diagnosis" as patients with no previous diagnosis of cancer, "established diagnosis" as patients with cancer and ongoing treatment and "relapse" as patients with cancer and ongoing treatment that had a prior cancer-free period. A frequentist analysis was performed including a multivariate logistic regression for mortality. Results: Two hundred and ten patients were included in the study; 30 (14%) died during the study period and 67% of patients who died were admitted to critical care. Demographics were similar in survivors and non-survivors. Patients with low weight for age (<-2SD) had higher mortality (28 vs. 3%, p = 0.019). There was statistically significant difference of mortality between patients with new diagnosis (36.7%), established diagnosis (1.4%) and relapse (60%), (p <0.001). Most patients had hematological cancers (69%) and they had higher mortality (18%) compared to solid tumors (6%, p= 0.032). Patients with concomitant bacterial infections had higher mortality (40%, p = 0.001). MIS-C, respiratory distress, cardiovascular symptoms, altered mental status and acute kidney injury on admission were associated with higher mortality. Acidosis, hypoxemia, lymphocytosis, severe neutropenia, anemia and thrombocytopenia on admission were also associated with mortality. A multivariate logistic regression showed risk factors associated with mortality: concomitant bacterial infection OR 3 95%CI (1.1-8.5), respiratory symptoms OR 5.7 95%CI (1.7-19.4), cardiovascular OR 5.2 95%CI (1.2-14.2), new cancer diagnosis OR 12 95%CI (1.3-102) and relapse OR 25 95%CI (2.9-214). Conclusion: Our study shows that pediatric patients with new onset diagnosis of cancer and patients with relapse have higher odds of all-cause mortality in the setting of COVID-19. This information would help develop an early identification of patients with cancer and COVID-19 with higher risk of mortality.

Children admitted to a pediatric intensive care unit after hematopoietic stem cell transplantation: Analysis of survival and predictors of mortality. / Niños con trasplante de progenitores hematopoyéticos admitidos en una unidad de cuidados intensivos: análisis de la sobrevida y los factores predictivos de mortalidad.

INTRODUCTION: Hematopoietic stem cell transplantation (HSCT) in children is a procedure that is not exempt of severe complications. Admission to the pediatric intensive care unit (PICU) is associated with a high mortality rate. Objectives: To analyze survival and predictors of mortality among children who received a HSCT and were admitted to the PICU, and to develop a mortality prediction model in this population. MATERIALS AND METHODS: Retrospective review of children and adolescents who received a HSCT between January 1st, 2005 and December 31st, 2019 and were admitted to the PICU of a tertiary care teaching hospital. RESULTS: Out of 264 children receiving the transplant, 114 were admitted to the PICU. The overall mortality rate was 29% (n = 34). The type of transplant, underlying disease, febrile neutropenia event, cytomegalovirus infection, respiratory failure, graft versus host disease (GVHD), myeloablative chemotherapy, and previous malnutrition were associated with higher mortality rates. In the multivariate analysis, GVHD (odds ratio [OR]: 2.23; 95% confidence interval [CI]: 1.92-2.98), need for mechanical ventilation (OR: 2.47; 95% CI: 1.39- 5.73), alternative donor transplant (OR: 1.58; 95% CI: 1.14-2.17), and previous malnutrition (OR: 1.78; 95% CI: 1.22-3.89) were associated with a higher mortality rate. CONCLUSION: In the studied population, 2 out of 3 children who received a HSCT and were admitted to the PICU survived. GVHD, mechanical ventilation, alternative donor transplant, and previous malnutrition were predictors of mortality.

Introducción: El trasplante de células progenitoras hematopoyéticas (TPH) en niños es un procedimiento no exento de complicaciones graves. El ingreso de esta población a unidades de cuidados intensivos pediátricos (UCIP) se asocia con elevada mortalidad. Objetivos: Analizar la sobrevida y los factores predictivos de la mortalidad en niños que recibieron TPH e ingresaron a la UCIP y elaborar un modelo predictivo de mortalidad en esta población. Materiales y métodos: Revisión retrospectiva de niños y adolescentes que recibieron un TPH entre el 01/01/2005 y el 31/12/2019 e ingresaron a la UCIP de un hospital universitario de alta complejidad. Resultados: De un total de 264 niños que recibieron el trasplante, 114 ingresaron a la UCIP. La mortalidad general fue del 29% (n = 34). El tipo de trasplante, enfermedad basal, evento de neutropenia febril, infección por citomegalovirus, insuficiencia respiratoria, enfermedad de injerto contra huésped (EICH), quimioterapia mieloablativa y desnutrición previa se asociaron con tasas de mortalidad más elevadas. En el análisis multivariado, la EICH (razón de posibilidades [OR, por su sigla en inglés]: 2,23; intervalo de confianza del 95% [IC 95%]: 1,92-2,98), la necesidad de ventilación mecánica invasiva (OR: 2,47; IC95%: 1,39-5,73), el trasplante de donante alternativo (OR: 1,58; IC 95%: 1,14-2,17) y la desnutrición previa (OR: 1,78; IC 95%: 1,223-3,89) se asociaron con mayor mortalidad. Conclusión: En la población estudiada, dos de cada tres niños que recibieron TPH e ingresaron a la UCIP sobrevivieron. La EICH, ventilación mecánica, trasplante de donante alternativo y desnutrición previa fueron factores predictivos de mortalidad.