Cytomegalovirus Infection Management in Multivisceral and Intestinal Transplant: A Dual Institution Study.

Intestinal transplant and multivisceral transplant were originally in pediatric populations and are relatively new procedures in adults. Despite increasing success rates in the immediate post-transplant period, infectious complications and acute and chronic rejection remain significant causes of morbidity and mortality. Previous research has shown cytomegalovirus (CMV) is the main cause of infection in this population. Due to the limited patient population, incidence of CMV viremia ranges widely and there is lack of universal protocol for treatment. This dual institution retrospective chart review between Henry Ford Hospital and Duke University analyzed adult intestinal and multivisceral transplant recipients between 2009 and 2019. Of the 32 patients identified and included in the study, 15 had CMV infection (46.9%). Of those with CMV infection, 5 (33.3%) had donor positive (D+)/recipient positive (R+) status; 5 had D-/R+; 4 had D+/R-; and one had D-/R-. There was no significant difference between mortality in those who had reported infection and not (80% vs 76.5%). The data from this study show significant rates of CMV viremia in patients undergoing intestinal transplant/multivisceral transplant with almost half of our study population having documented infection within 1 year of transplant, stressing the importance for universal protocol into CMV viremia treatment.

Elevated liver enzymes portends a higher rate of complication and death in SARS-CoV-2.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2, or coronavirus disease-2019 (COVID-19), has infected millions worldwide since its discovery in Wuhan, China in December 2019, but little is still known about the disease process. Preliminary research in China notes liver function tests (LFTs) abnormalities are common in COVID-19 patients, suggesting decreased hepatic function, and that abnormalities in LFTs are related to complicated disease course and negative outcomes. However, there has been limited large-scale data assessing COVID-19's association with liver dysfunction and negative outcomes. AIM: To investigate how COVID-19 affects the liver function and disease course in patients infected with the virus treated at Henry Ford Hospital from March to September 2020. METHODS: A total of 8028 patients infected with COVID-19 were identified and included in the study at a single academic center. Data from medical charts on laboratory testing including aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (AP), and bilirubin levels, past history of liver disease, and disease course indicators including hospital admission, intensive care unit (ICU) admission, intubation, and death were recorded and analyzed. Elevated liver enzymes were defined as ALT/AST greater than 60, AP greater than 150, or bilirubin greater than 1.5, super-elevated liver enzymes were defined as ALT/AST greater than 120, AP greater than 300, or bilirubin greater than 3.0. RESULTS: A total of 8028 COVID-19 patients were identified and included in the study. Data from medical charts on LFTs (namely, AST, ALT, AP, and bilirubin levels), past history of liver disease, and disease course indicators (hospital/ICU admission, intubation, death) were recorded and analyzed. LFTs from 3937 patients were available for interpretation. 45% were found to have elevated or super-elevated LFT. When compared to COVID-19 patients without elevated LFTs, this cohort was found to have significantly higher odds of hospital admittance, ICU admission, intubation, and death (all P < 0.001). 248 (3.1%) had a history of liver disease. Those with elevated and super elevated LFTS had significantly higher odds of having a past history of liver disease (P < 0.001). CONCLUSION: The findings from this study suggest that in patients who have tested positive for COVID-19, those with elevated and super elevated liver enzyme levels have significantly higher odds of hospital admittance, ICU admittance, intubation and death in comparison to those COVID-19 patients without elevated liver enzyme levels.

Parental Proxy PROMIS Pain Interference Scores are Only Modestly Concordant With Their Child's Scores: An Effect of Child Catastrophizing.

OBJECTIVES: Pediatric patients with chronic musculoskeletal conditions such as idiopathic scoliosis awaiting surgical correction can experience pain that interferes with their daily functioning. Reports of this interference are commonly gathered from patients through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Scale and through parent-proxy scores. However, the child and parent/caregiver reports vary. To provide appropriate treatment for young patients with pain, the nature of the discrepancies and under which circumstances the reports differ needs to be understood. This report offers new information on the level of concordance among parent and child report of pain interference within this patient population, and which parent and child characteristics may influence concordance rates. METHODS: Youth (age=10 to 17 y) with a history of musculoskeletal disorders, including idiopathic scoliosis, under consideration for surgical correction of that scoliosis and parent/caregiver dyads (n=103) completed the PROMIS Pain Interference Scale during an orthopedic presurgical visit. The current data was taken from a larger study examining postsurgical pain among patients undergoing orthopedic surgical procedures to correct scoliosis. The purpose of the current study was to measure the degree of agreement between parent and child reports of pain interference and discovery of relationships among predictors of pain interference score correspondence among dyads. RESULTS: Correspondence between parent/caregiver and child reports of pain interference was modest (intraclass correlation coefficient=0.530). In total, 46% of dyads had similar pain interference scores, whereas 24% of parents reported higher pain interference in comparison to their child, the remaining 30% reported lower pain interference in relation to their child's report. Among children where discrepancies appeared, using logistic regression models, only child catastrophizing scores were associated with differences in parent and child estimation of child's pain interference scores. No parental characteristics predicted discrepancies between dyad pain interference reports. DISCUSSION: Parent-proxy and child reports generally correspond, but when discrepant, 24% of parents reported higher pain interference in relationship to the child report of pain interference and 31% noted less intense pain interference than their child's pain interference. Given these results, care should be taken when interpreting parent reports of child pain interference, especially when a child reports higher degrees of pain interference.

A cluster of high psychological and somatic symptoms in children with idiopathic scoliosis predicts persistent pain and analgesic use 1 year after spine fusion.

BACKGROUND: Persistent postoperative pain is a significant problem for many children, particularly for those undergoing major surgery such as posterior spine fusion. More than two-thirds report persistent pain after spine fusion, yet factors that may contribute to poorer outcomes remain poorly understood. AIMS: This prospective, longitudinal study examined how psychologic and somatic symptoms cluster together in children aged 10-17 years with idiopathic scoliosis, and tested the hypothesis that a higher psychological and somatic symptom cluster would predict worse pain outcomes 1 year after fusion. METHODS: Otherwise healthy children with idiopathic scoliosis completed preoperative surveys measuring recent pain intensity, pain location(s), somatic symptom severity, painDETECT (neuropathic-type pain symptoms), pain interference, fatigue, depression, anxiety, and pain catastrophizing. Pain outcome data were collected during hospitalization, and at 1 year after surgery. RESULTS: Ninety-five children completed baseline surveys and a cluster analysis differentiated 28 (30%) with a high symptom profile that included; higher depression, fatigue, pain interference, catastrophizing, and painDETECT scores. High symptom cluster membership independently predicted higher pain interference at 1 year (ß 9.92 [95% CI 6.63, 13.2], P < 0.001). Furthermore, children in this high symptom cluster reported significantly higher pain intensity and painDETECT scores, and had a 50% higher probability of continued analgesic use at 1 year compared to those in the Low Symptom Cluster (95% CI 21.3-78.5, P = 0.001). CONCLUSION: Findings from this exploratory study suggest a need to comprehensively assess children with scoliosis for preoperative signs and symptoms that may indicate an underlying vulnerability for persistent pain. This, in turn may help guide a comprehensive perioperative treatment strategy to mitigate the potential for long-term pain trajectories.