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Background: The importance of identifying mortality biomarkers in chronic kidney disease (CKD), and especially in patients treated with hemodialysis (HD), has become evident. In addition to being a marker of tubulointerstitial injury, plasma kidney injury molecule-1 (KIM-1) has been mentioned in regard to HD patients as a risk marker for cardiovascular (CV) mortality and coronary artery calcification. The aim of this study was to assess the level of plasma KIM-1 as a marker of cardiovascular disease (CVD) and mortality in CKD5-HD patients (patients with CKD stage G5D treated with hemodialysis)., Methods: We conducted a prospective case-control study that included 63 CKD5-HD patients (HD for 1-5 years) followed up for 48 months and a control group consisting of 52 non-dialysis patients diagnosed with CKD stages G1-G5 (ND-CKD). All patients had a CVD baseline assessment including medical history, echocardiography, and electrocardiography (ECG). Circulating plasma KIM-1 levels were determined with single-molecule counting immunoassay technology using an enzyme-linked immunosorbent assay. We obtained the following parameters: serum creatinine and urea; the inflammation markers CRP (C-reactive protein) and IL-6 (interleukin-6); and the anemia markers complete blood count, serum ferritin, and transferrin saturation (TSAT)., Results: The mean plasma KIM-1 level was 403.8 ± 546.8 pg/mL, showing a statistically significant correlation with inflammation (CRP, R = 0.28, p = 0.02; IL-6, R = 0.36, p = 0.005) and with anemia (hematocrit, R = -0.5, p = -0.0316; hemoglobin (Hb), R = -0.5, p = 0.02). We found that patients with left ventricular hypertrophy (LVH) on echocardiography (59.7%) had significantly lower mean levels of plasma KIM-1 than patients from the control group (155.51 vs. 432.12 pg/mL; p = 0.026). Regarding the patients' follow-up, we assessed all-cause mortality as an endpoint. After 24 months of follow-up, we found a mortality rate of 22.23%, while after 48 months, the mortality rate was 50.73%. A plasma KIM-1 level < 82.98 pg/mL was significantly associated with decreased survival in hemodialysis patients ( p < 0.001)., Conclusions: In patients treated with hemodialysis, low levels of plasma KIM-1 were associated with cardiovascular changes and an increased risk of mortality. Plasma KIM-1 levels were significantly higher in HD patients compared to ND-CKD patients.

Background: The standard vancomycin regimen for term neonates is 45 mg/kg/day. However, the optimal starting vancomycin dosing for achieving therapeutic levels in young infants in cardiac intensive care units remains unknown. Moreover, data on the association of supratherapeutic vancomycin levels with acute kidney injury (AKI) are limited., Methods: Retrospective study of infants ≤3 months old, receiving vancomycin following congenital heart surgery at postoperative intensive care unit admission. Assessed were vancomycin dosing, achievement of therapeutic trough concentration of 10-20 mg/L and development of AKI, based on the modified Kidney Disease Improving Global Outcomes criteria., Results: Inclusion criteria were met by 109 patients with a median age of 8 days (IQR: 6-16). The mean (SD) vancomycin dose required for achieving therapeutic concentration was 28.9 (9.1) mg/kg at the first postoperative day. Multivariate logistic regression identified higher preoperative creatinine levels and shorter cardiopulmonary bypass time as predictors of supratherapeutic vancomycin concentrations (c-index 0.788). During the treatment course, 62 (56.9%) developed AKI. Length of stay and mortality were higher in those who developed AKI as compared with those who did not. Multivariate logistic regression identified higher vancomycin concentration as a predictor for postoperative AKI, OR, 3.391 (95% CI: 1.257-9.151), P = 0.016 (c-index 0.896)., Conclusion: Our results support a lower starting vancomycin dose of ~30 mg/kg/day followed by an early personalized therapeutic approach, to achieve therapeutic trough concentrations of 10-20 mg/L in cardiac postoperative term infants. Supratherapeutic concentrations are associated with an increased risk for AKI, which is prevalent in this population and associated with adverse outcomes., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: Extracorporeal membrane oxygenation (ECMO) serves as cardiopulmonary therapy in critically ill patients with respiratory/heart failure and often necessitates multiple blood product transfusions. The administration of platelet transfusions during ECMO is triggered by the presence or risk of significant bleeding. Most paediatric ECMO programmes follow guidelines that recommend a platelet transfusion threshold of 80-100 × 10 9 /L. To reduce exposure to platelets, we developed a practice to dynamically lower the threshold to ~20 × 10 9 /L. We describe our experience with patient-tailored platelet thresholds and related bleeding outcomes., Materials and Methods: We retrospectively evaluated our platelet transfusion policy, bleeding complications and patient outcome in 229 ECMO-supported paediatric patients in our unit., Results: We found that more than 97.4% of patients had a platelet count <100 × 10 9 /L at some point during their ECMO course. Platelets were transfused only on 28.5% of ECMO days; and 19.2% of patients never required a platelet transfusion. The median lowest platelet count in children who had bleeding events was 25 × 10 9 /L as compared to 33 × 10 9 /L in children who did not bleed (p < 0.001). Our patients received fewer platelet transfusions and did not require more red blood cell transfusions, nor did they experience more haemorrhagic complications., Conclusion: We have shown that a restrictive, 'patient-tailored' rather than 'goal-directed' platelet transfusion policy is feasible and safe, which can greatly reduce the use of platelet products. Although there was a difference in the lowest platelet counts in children who bled versus those who did not, the median counts were much lower than current recommendations., (© 2024 The Authors. Vox Sanguinis published by John Wiley & Sons Ltd on behalf of International Society of Blood Transfusion.)

Chronic kidney disease patients treated by hemodialysis present a high cardiovascular morbidity and mortality. There is an imperative need for novel biomarkers for identifying these patients and to offer possible therapeutically interventions. We performed a prospective observational cohort study on 77 patients in the period of October 2021-October 2023. We measured serum plasma levels of interleukin 1-beta, galectin 3, human suppression of tumorigenicity factor 2, bone morphogenetic protein 2 and fibroblastic growth factor 23 at the inclusion site. We evaluated the correlations of these biomarkers with cardiac function and structure evaluated by echocardiography. The mean age was 61.02 (±11.81) years, with 45 (56.2%) males and with a dialysis vintage of 4.95 (2.4-7.8) years. Median ejection fraction was 51 (43-54%), and more than two-thirds of the patients presented valvular calcifications. Overall mortality was 22%. Interleukin 1-beta was correlated positively with ejection fraction and global longitudinal strain and negatively with left atrium diameter and left ventricle telesystolic diameter. Galectin 3 values were negatively correlated with aortic valve fibrosis and mitral valve calcifications, and human suppression tumorigenicity factor 2 was negatively correlated with mitral valve calcifications. Some of these novel biomarkers could be used to better assess cardiovascular disease in patients on maintenance hemodialysis.

Background: Data on breastfeeding rates and targeted interventions in women with pre-gestational diabetes mellitus are inconclusive. The aim of the study was to evaluate breastfeeding rates up to one year postpartum and whether targeted counseling towards the end of pregnancy can impact breastfeeding rates and duration. An additional goal was to evaluate whether counseling affected women's perceptions regarding breastfeeding., Methods: Women with pre-gestational diabetes mellitus were cluster-randomized between 32 and 36 weeks of gestation, either to face-to-face instruction with a certified lactation consultant or to receive written information on breastfeeding. Thirty-eight women without diabetes served as controls and were given written information on breastfeeding. All women filled out a questionnaire regarding intended breastfeeding duration, exclusivity, and perceptions, before intervention and at three, six, and twelve months post-partum., Results: Fifty-two women with pre-gestational diabetes mellitus consented to participate. All completed the questionnaires, 26 in each group. At three, six, and twelve months postpartum, rates of any breastfeeding were around 60%, 50%, and 30%, respectively. Approximately one-third breastfed exclusively in each group at three and six months. No significant difference in breastfeeding rates was noted between face-to-face instruction, written information, and controls. End-of-pregnancy counseling improved confidence in breastfeeding knowledge and confidence in being able to manage blood glucose., Conclusions: Breastfeeding rates in pre-gestational diabetes mellitus were comparable to those of women without diabetes and were unchanged by mode of instruction at the end of pregnancy. However, targeted diabetes-oriented breastfeeding instruction at the end of pregnancy improved knowledge and confidence among women with pre-gestational diabetes mellitus.

Background: Some patients with pulmonary stenosis present with a complex multilevel disease that involves the valve, the leaflets, and the sinotubular junction (STJ) forming an hourglass appearance. We herein report the mid-term results of our experience with the reconstruction of the supravalvar narrowing using three pericardial patches., Material and Methods: Retrospective analysis of patient charts and echocardiography studies of patients who underwent three-patch reconstruction of the pulmonary valve (PV) from 2013 to 2022. After PV transection distal to STJ, vertical incisions into the sinuses were performed, and leaflets were trimmed and thinned. The three sinuses were augmented using three pericardial patches., Results: Nineteen patients underwent repair of hourglass supravalvar pulmonary stenosis. Mean weight at surgery was 9.4 kg (median 7.2, range 4.7-35); 16 patients underwent previous catheterization with unsuccessful balloon dilatation of the PV (13 pts.). Preoperative aortic/pulmonary annulus ratio was 1.02 (median 1, range 0.89-1.25). After surgery, gradients across the PV were significantly reduced (94 ± 26 vs 29 ± 9 mm Hg, P  = .02). Postoperatively, 14 patients had mild or no pulmonary insufficiency (PI) and five had mild to moderate PI. At a mean follow-up of 71 months (median 78 months, range 8-137), gradients continued to decrease (29 ± 9 vs 15 ± 5 mm Hg, P  < .001)., Conclusion: The three-patch technique for the repair of supravalvar pulmonary stenosis is simple, reproducible, and achieves excellent and long-standing relief of the right ventricular outflow tract gradient., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Ventricular assist devices (VADs) play a critical and increasing role in treating end-stage heart failure in pediatric patients. A growing number of patients are supported by VADs as a bridge to heart transplantation. Experience with VADs in the pediatric population is limited, and experience in Israel has not been published., Objectives: To describe this life-saving technology and our experience with VAD implantation in children with heart failure, including characteristics and outcomes., Methods: We conducted a retrospective chart review of all patients who underwent VAD implantation at Schneider Children's Medical Center from 2018 to 2023., Results: We analyzed results of 15 children who underwent VAD implantation. The youngest was 2.5 years old and weighed 11 kg at implantation. In eight patients, HeartMate 3, a continuous-flow device, was implanted. Seven patients received Berlin Heart, a pulsatile-flow device. Three children required biventricular support; 11 underwent heart transplants after a median duration of 169 days. Two patients died due to complications while awaiting a transplant; two were still on VAD support at the time of submission of this article. Successful VAD support was achieved in 86.6% of patients. In the last 5 years,79% of our heart transplant patients received VAD support prior to transplant., Conclusions: Circulatory assist devices are an excellent bridge to transplantation for pediatric patients reaching end-stage heart failure. VADs should be carefully selected, and implantation techniques tailored to patient's weight and diagnosis at a centralized pediatric cardiac transplantation center. Israeli healthcare providers should be cognizant of this therapeutic alternative.

Introduction: East-European data on cancer in patients undergoing hemodialysis (HD) are scarce. This study aimed to assess the pattern of cancer and related mortality in patients with end-stage kidney disease (ESKD) undergoing HD., Methods: Retrospectively analyzing data from 7 HD centers, this study examined 1377 incident HD patients divided into three groups: no-cancers (NoC), cancers that occurred prior to HD initiation (CPI) and de novo cancer developed after HD initiation (DNC). Mortality risk and survival trends within groups were analyzed using Cox regression and Kaplan-Meier methods., Results: In the cohort, 89.46% of the patients had no cancer (NoC group), 3.63% had cancer before (CPI group), and 6.89% had cancer after HD initiation (DNC group). The mean time from HD initiation to DNC diagnosis was 1 [2.75] years. Older age was associated with a higher risk of developing DNC ( p  < 0.001). Chronic tubulointerstitial nephritis (CTIN) is more prevalent in cancer patients. The most common cancer sites among DNC patients were the digestive (29.47%) and urinary tracts (18.95%), while those in CPI subjects were hematologic (22%) and digestive (20%). Cancer was an independent predictor of mortality risk (HR = 6.9, 95% [CI]:4.5-10.6, p  < 0.001)., Conclusions: East-European ESKD patients undergoing HD have a high incidence of de novo cancers whose primary cancer sites are the digestive and urinary tracts. Almost half of the HD patients with CPI have hematologic and digestive tract cancers. Age and CTIN were associated with cancer risk. Cancer is an independent risk factor for all-cause mortality in patients undergoing hemodialysis (HD).

Purpose: End-stage kidney disease patients (ESKD) receiving hemodialysis (HD) are at a greater risk of hepatitis virus (HV) infections due to the invasive nature of the procedures, frequent hospital stays and surgeries, as well as the immune deficiency status of ESKD., The Aim: This study was to reassess the hepatitis virus infections prevalence in the HD population in Romania after 5 years of oral DAAs therapy and assess the impact on HD patients' outcomes in two cohorts (2015 and 2019)., Methods: We compared ESKD patients treated with HD in 10 HD centers from the historical regions of Romania in 2015 (n = 1401, Mean age 59.7 ± 12.92 years) with patients treated in the same centers in 2019 (n = 1698, mean age 61 ± 12.93 years). All patients went through HD therapy for more than 90 days., Results: The patients from the 2019 cohort were significantly older (p = 0.005), had a longer duration of HD therapy (p < 0.0001), and had more vascular calcifications (p = 0.015); the crude one-year mortality rate did not differ from the 2015 cohort (9.9 vs. 10.7%, p = 0.46). The prevalence of HBV infection did not differ between the cohorts (4.7% vs. 4.8, p = 0.604) but the prevalence of HCV significantly decreased from 2015 to 2019 (16.9 vs. 10.5%, p < 0.0001)., Conclusion: After 15 years of a nationwide infection prevention program for HV infections and 5 years of DAAs treatment in Romania, the prevalence of HBV did not change but HCV infections decreased significantly, however, it still remained high., (© 2023. The Author(s).)

Purpose: The aim of this study was to evidence trends and changes in mortality, comorbid conditions, prognosis, and causes of death after 5 years of continuous evolution of hemodialysis (HD) patients in Romania., Methods: We included two cohorts of stable HD patients (901 from 2012 and 1396 from 2017). Both cohorts were followed up for 1 year. The 5-year survivors of the 2012 cohort were identified in 2017 and their data changes were assessed., Results: The 2017 patients were older, with longer time on dialysis, higher serum creatinine and urea levels, and required higher ultrafiltration volume per dialysis. They also had lower hemoglobin, lower C-reactive protein, higher albumin, higher calcium bicarbonate, and higher parathyroidectomy prevalence. The 2017 cohort presented with lower average dialysis flow, less administration of iron sucrose, had more catheters, lower hepatitis C prevalence, higher diabetes mellitus prevalence, higher heart valve calcifications, higher heart rate disorders, higher prevalence of left ventricular hypertrophy, and lower ejection fraction. Cardiovascular disease was the main cause of death in both years (50% in 2012 and 45.6% in 2017), followed by sepsis and cancer. The mortality was higher in 2017 compared to 2012 (14.1 vs 6.6%). The 5-year mortality was 37.2% with an average of 7.44%/year. The risk of death increased with age, higher C-reactive protein, higher phosphate, lower hemoglobin, and lower albumin., Conclusion: Cardiovascular disease remains the main causes of death in HD-treated patients but with decreasing trend. Developing regional therapeutic strategies for quality care with early intervention will most likely improve mortality., (© 2023. The Author(s).)

Differentiating between thyroid and parathyroid lesions by means of ultrasound can be a challenge in some cases. This study explores the diagnostic efficacy of bidimensional shear wave elastography planewave ultrasound (2D SWE PLUS) as an auxiliary technique in distinguishing these superficial structures. We evaluated 86 cases, presenting with concurrent thyroid nodules and hyperparathyroidism, through conventional ultrasound and 2D SWE PLUS, employing an Aixplorer Supersonic Mach30 with a 5-18 MHz linear probe. Statistically significant differences were observed for the elasticity index (EI) between parathyroid and normal thyroid tissue (p<0.0001, U=291), and between parathyroid lesions and thyroid nodules (p<0.0001, U=248.5). An area under the curve (AUC) of 0.961, with an optimal cut-off value of ≤8.9 kPa, was established to effectively distinguish parathyroid tissue from normal thyroid tissue (sensitivity of 91.9%; specificity of 97.5%). Furthermore, an AUC of 0.963 and an optimal cut-off of 9.24 kPa (sensitivity of 94.2%, specificity of 91.1%) were determined for parathyroid vs thyroid lesions. Elasticity values were significantly elevated in the cancer group compared to benign thyroid nodules (p<0.0001). Our findings suggest that 2D SWE PLUS is an effective tool in differentiating between thyroid nodules and parathyroid lesions, enhancing diagnostic performance in neck ultrasonography., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Stoian, Borlea, Taban, Maralescu, Bob, Schiller, Schiller and Neagoe.)

Objective: Blood stream infections (BSIs) are well described in pediatric cardiac intensive care units (PCICU). We noted that postoperative high-risk patients may develop BSI after a preceding clinical event (PCE). The study aim was to investigate whether high-risk patients who developed bacteremia experienced more PCEs than a similar group of high-risk patients. Design: Retrospective case-control study. Setting: Referral pediatric center. Patients: We enrolled patients who developed bacteremia from March 2010 to November 2019, after undergoing open-heart surgery at a pediatric center. The control group was comprised of case-matched patients with immediate consecutive same surgery. Interventions: None. Measurements: We recorded operative data, common risk factors, postoperative indicators of organ dysfunction, mortality, and PCEs 72 to 24 h before bacteremia emerged. Main results: A total of 200 patients were included (100 with bacteremia and 100 controls). Key demographic and operative parameters were matched. Bacteremia emerged on average on postoperative day 12.8. Skin-associated Gram-positive bacteria were cultured in 10% and Gram-negative bacteria in 84% of the patients. Average central-venous lines (CVL) duration was 9.5 ± 8.4 days. Postoperatively (72 h), indicators of organ dysfunction were significantly worse in patients with bacteremia, with a higher rate of postoperative complications during PCICU length-of-stay (LOS). In the bacteremia group, 72 to 24 h prior to the development of bacteremia, 92 (92%) PCEs were recorded, as compared to 21 (21%) in controls during their entire LOS (odds ratio [OR] 43.3, confidence interval [CI] 18.2-103.1, P  < .0001). Conclusions: We propose a 3-hit model demonstrating that high-risk patients undergoing open-heart surgery have significantly higher risk for bacteremia after a PCE.

Objective: Ultrasound (US)-guided durable tunneled femoral central venous catheters (TF-CVCs) are a safe central venous access option in infants and neonates. Studies have shown, however, that femoral central venous access has the potential for high central line-associated bloodstream infection (CLABSI) rates with a significant increase in risk for line-related thrombosis. Our aims were to describe the bedside insertion technique and evaluate the safety and complication rates of TF-CVCs in high-risk, young, pediatric cardiac intensive-care unit (PCICU) population., Design: A retrospective observational cohort study., Setting: University affiliated, tertiary-care hospital, PCICU., Patients: All PCICU patients that underwent bedside TF-CVC insertion were enrolled. Data was collected from the electronic medical record system., Interventions: None., Measurements and Main Results: During April 2016 to October 2021, 103 TF-CVC lines were inserted into 94 pediatric cardiac critical care patients, at the bedside. Patients' characteristics were median (IQR) age of 47.5 days (22.6, 120.5), weight 3.3 kg (2.9, 4.3), 33% prevalence of genetic anomalies, need for ECMO support in 20.4%, and STAT category 4-5 in 53.4%. All procedures were performed by intensivists. There were no immediate procedure-related complications. TF-CVCs were inserted on average on post-operative day (POD) 14, median line indwell duration was 25 days (16.3, 42.3) and total TF-CVC dwell duration for the entire cohort of 3442.7 days. During the study period eight CLABSI events were recorded (2.3/1000 line-days). Line obstruction rate was 1.16/1000 line-days and six lines were dislodged in the intermediate-care unit. There was no symptomatic line-related thrombosis., Conclusions: We show that US-guided durable tunneled femoral central venous catheter (TF-CVC) insertion by an intensivist at the bedside is a technically feasible and safe prolonged central venous access option in critically ill, high-risk infants and neonates in the PCICU.

Rational and Objectives: Non-invasive cardiac output (CO) measurements are essential during the immediate post-operative course of young, congenital heart repaired patients. The use of the Ultrasonic Cardiac Output Monitor (USCOM) in pediatric intensive care units (PICU) is increasing. The literature on accuracy of USCOM in young, critically ill, mechanically ventilated, hemodynamically supported patients is scarce. We aimed to assess agreement between the USCOM device and echocardiography for measurements of CO in this population., Materials (patients) and Methods: A prospective observational study in a pediatric cardiac intensive care unit (PCICU). Paired CO measurements were taken in young, mechanically ventilated, immediate post-operative patients with exclusion of unrepaired or residual intra-cardiac shunt, using USCOM and echocardiography, by two separate senior performers. Agreement between echocardiography and USCOM was assessed by percentage error and Bland-Altman analysis., Results: One hundred and thirteen comparison scans were performed on 61 patients: mean age 94 ± 111 d, weight 4.7 ± 2.1 kg, vaso-inotropic score 15.3 ± 11, and STAT score 3-4 (46%). Mean USCOM cardiac index (CI) percent difference was -9.6% (45.6) and velocity-time-integral (VTI) 8.9% (34.7). Bland-Altman analyzes demonstrated poor agreement comparing USCOM to echocardiography with regard to CI, stroke volume (SV), VTI and aortic diameter (AO) measurements., Conclusion: Our study shows that USCOM underestimates CI in comparison with echocardiography; therefore USCOM should be used with great caution as an absolute estimate or surrogate of CI in neonates and infants in the immediate post-operative, congenital heart surgery period.

Aim: This study aimed to describe epidemiological and clinical characteristics of Serratia bacteraemia and to identify factors associated with mortality., Methods: The microbiology database of Schneider Children's Medical Centre of Israel was examined for Serratia marcescens positive blood cultures, between January 2007 and May 2020. Demographic, clinical and microbial characteristics were analysed., Results: Of the 81 patients files that met the inclusion criteria, 64 (80%) were of patients hospitalised in paediatric intensive care units. The median age was 78 days and 54% were male. In-hospitalisation mortality was 26%, 62% died under 90 days old. Underlying conditions including prematurity, congenital cardiac defects and malignancies were noted in 95% of patients. Prior to the bloodstream infections, 62% of patients underwent procedures, 64% were on ventilatory support and 77% had central lines. Thrombocytopenia and elevated C-reactive protein levels were found in 60% of the children. Twenty-eight children received definitive monotherapy as either piperacillin-tazobactam or a third-generation cephalosporin; survival rates were similar between the two antibiotic treatment groups., Conclusion: In our cohort, 26% died. Death was more common in young infants. Mortality was associated with hospitalisation in intensive care units and thrombocytopenia. Survival rates following definitive monotherapy were similar for patients treated with piperacillin-tazobactam and those treated with third-generation cephalosporin., (© 2022 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Objective: Routine use of central venous access is needed in children undergoing open heart surgery for pressure monitoring and inotrope infusion. We sought to evaluate the efficiency and safety of routine use of transthoracic intracardiac lines (ICLs) in patients undergoing cardiac surgery and to compare them to patients who have been previously treated with traditional central venous lines (non-ICLs)., Methods: Retrospective review of charts of all patients who underwent cardiac surgery and had an ICL inserted in the operating room. Case control matching was done with similar patient in which ICL was not inserted. Patients characteristics, diagnosis, operative, and intensive care data were collected for each patient and analyzed., Results: A total number of 376 patient records were reviewed (198 ICL patients and 178 non-ICL patients). Umbilical line and non-ICL durations were longer in the non-ICL group. ICL duration was the longest of all lines, averaging 12.87 ± 10.82 days. The necessity for multiple line insertions (˃2 insertions) was significantly higher in the non-ICL group, with a relative risk ratio of 3.24 (95% confidence interval: 1.617-6.428). There was no statistical difference of infections rate and line complications between the two groups., Conclusion: ICLs are safe in infants undergoing cardiac surgery and can be kept in place for a long period of time with a low rate of line complications and infection. Routine use of ICLs reduces the number of central venous catheter placement in this complex patient population., (© 2022 Wiley Periodicals LLC.)

Introduction: In hemodialysis patients, coronavirus disease 2019 is associated with high morbidity and mortality. Aim of the study was to evaluate the antibody level against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients treated with two different mRNA-based vaccines, in a multicenter survey., Patients and Methods: Since April 2020, in the 5 participating Centers, periodic screening of all patients with PCR testing has been performed every 2 weeks. The study included two cohorts of patients on maintenance hemodialysis treated with the BNT162b2 or with the mRNA-1273 Covid-19 vaccine. The tests for antibodies against the receptor-binding domain was performed by the anti-SARS-CoV-2 S enzyme immunoassay (Roche Elecsys)., Results: Of the 398 included patients, 303 received the BNT162b2 and 95 the mRNA-1273 vaccine. In patients without previous infection, the median levels of anti-S antibodies were 297 U/mL and 1,032 U/mL for those treated with BNT162b2 or mRNA-1273, respectively (p < 0.001). In patients with previous infection, the median levels of SARS-CoV-2 anti-S antibodies were 7,516 U/mL and 17,495 U/mL for those treated with BNT162b2 or mRNA-1273, respectively (p = 0.005). The Charlson comorbidity index (CCI) was significantly associated with protective levels of anti-spike IgG, with 3.6% of low- or non-responders having a CCI of 2-4 versus 18.9% in those with a CCI of 8 or more. The adjusted OR of developing a sufficient antibody level between the two vaccines was 3.91 (p = 0.0766) in favor of mRNA-1273., Conclusions: Both of the evaluated mRNA-based vaccines for SARS-CoV-2 showed good efficacy. Preliminary data may data suggest a  higher antibody response to the mRNA-1273 vaccine., (© 2021. The Author(s) under exclusive licence to Italian Society of Nephrology.)

Objective: Acute low cardiac output (CO) is a frequent scenario in pediatric cardiac intensive care units (PCICU). While fluid responsiveness has been studied extensively, literature is scarce for the immediate postoperative congenital heart surgery population admitted to PCICUs. This study analyzed the utility of hemodynamic, bedside ultrasound, and Doppler parameters for prediction of fluid responsiveness in infants and neonates in the immediate postoperative cardiac surgery period., Design: A prospective observational study., Setting: University affiliated, tertiary care hospital, PCICU., Participants: Immediate postoperative pediatric patients displaying a presumed hypovolemic low CO state were included. A clinical, arterial derived, hemodynamic, sonographic, Doppler-based, and echocardiographic parameter assessment was performed, followed by a fluid bolus therapy., Interventions: Fifteen to 20 cc/kg crystalloid fluid bolus., Main Outcome Measures: Fluid responsiveness was defined as an increase in cardiac index >10% by echocardiography., Results: Of 52 patients, 34 (65%) were fluid responsive. Arterial systolic pressure variation, continuous-Doppler preload parameters, and inferior vena-cava distensibility index (IVCDI) by bedside ultrasound all failed to predict fluid responsiveness. Dynamic central venous pressure (CVP) change yielded a significant but modest fluid responsiveness predictability of area under the curve 0.654 (P = 0.0375)., Conclusions: In a distinct population of mechanically ventilated, young, pediatric cardiac patients in the immediate postoperative period, SPV, USCOM preload parameters, as well as IVC-based parameters by bedside ultrasound failed to predict fluid responsiveness. Dynamic CVP change over several hours was the only parameter that yielded significant but modest fluid responsiveness predictability., Competing Interests: No funding was procured for this work. Mrs. Shochat disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest. The authors report no conflicts of interests., (Copyright © 2021 by the Shock Society.)

Left ventricular (LV) structure and function anomalies are frequent during the CKD continuum and are associated with increased risk of mortality. Cross section and longitudinal ultrasound data are available for advanced CKD and transition to ESKD. Less information is available about LV changes during stable, long-term hemodialysis (HD) treatment. All stable HD patients from 9 HD centers (1034 patients, 671 males, age 58.71 ± 12.94 years) have been enrolled in January 2015. The cohort was followed-up for 4 years, kidney transplantation or death. Yearly, two-dimensional and M-mode continuous and Pulse Doppler echocardiography were performed. During the follow-up, the prevalence of cardiovascular comorbidities significantly increased (p < 0.0001), coronary artery disease (CAD) from 73.5 to 88.8%, peripheral artery disease (PAD) from 29 to 40.9%, cerebral vascular disease (CVD) from 20.4 to 30.8%, heart valves calcification (VC) from 65.6 to 89.3% and left ventricular hypertrophy (LVH) from 67.6 to 76.5%. The mortality risk increased with the presence of CAD (1.59-fold), PAD (1.61-fold), CVD (1.59-fold), and VC (1.77-fold). Mortality risk was increased in those with LVEF < 50% (LVEF 40-49% 1.5-fold and LVEF < 40% 2.3 fold). Among the survivors of the first year, LVEF varied (> 5% decrease, > 5% increase and ± 5% variations). More than 5% increase of LVEF was associated with higher mortality risk (crude 1.5-fold, adjusted 1.43-fold) compared to stationary EF (p = 0.001). Cardiovascular disease progresses during stable long-term HD therapy and increases mortality risk. HF becomes highly prevalent but only HF with decreased LVEF < 50% is associated with increased risk of mortality.

This is the first published case, as far as we know, of a term neonate with refractory chylothorax secondary to diastolic dysfunction in the cardiac postoperative period, where extracorporeal membrane oxygenation (ECMO) was used to improve the physiologic derangements, thus allowing resolution of the chylous effusion. The infant was prenatally diagnosed with d-transposition of the great arteries. He was started on prostaglandin infusion and underwent balloon atrial septostomy followed by arterial switch operation. After surgery, he developed anasarca and high-volume chylothorax that did not respond to medical management and fasting. Cardiac catheterization demonstrated severe diastolic dysfunction and pulmonary hypertension. On postoperative day 19, he was placed on veno-arterial (VA) ECMO and had gradual regression of the chylothorax and edema. After 13 days on ECMO support, he was decannulated with small, self-limiting, reaccumulation of chylous effusion. He was discharged home on postoperative day 57, and has since been thriving with no evidence of reaccumulation of the chylous effusion. In summary, VA ECMO support could be considered as a rescue modality for patients with uncontrollable refractory high-volume chylous effusion, after other treatment options have been pursued., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © 2021 by the ASAIO.)

Objectives: In this study, we aim to determine the elastographic characteristics of both primary and secondary hyperparathyroidism using shear wave elastography. We also aim to evaluate the elastographic differences between them, as well as the differences between the parathyroid, thyroid, and muscle tissue, in order to better identify a cutoff value for the parathyroid tissue., Methods: In this prospective study, we examined a total of 68 patients with hyperparathyroidism, divided into two groups; one group consisted of 27 patients with primary hyperparathyroidism and the other group consisted of 41 selected patients with confirmed secondary hyperparathyroidism. The elasticity index (EI) was determined in the parathyroid, thyroid, and muscle tissue. The determined values were compared to better identify the parathyroid tissue., Results: The median value of mean SWE values measured for parathyroid adenomas from primary hyperparathyroidism was 4.86 kPa. For secondary hyperparathyroidism, the median value of mean SWE was 6.96 KPa. The median (range) presurgical values for parathormone (PTH) and calcium were 762.80 pg/mL (190, 1243) and 9.40 mg/dL (8.825, 10.20), respectively. We identified significant elastographic differences between the two groups ( p < 0.001), which remained significant after adjusting elastographic measures to the nonparametric parameters, such as the parathormone value and vitamin D ( p < 0.001). The cutoff values found for parathyroid adenoma were 5.96 kPa and for parathyroid tissue 9.58 kPa., Conclusions: Shear wave elastography is a helpful tool for identifying the parathyroid tissue, in both cases of primary and secondary hyperparathyroidism, as there are significant differences between the parathyroid, thyroid, and muscle tissue. We found a global cutoff value for the parathyroid tissue of 9.58 kPa, but we must keep in mind that there are significant elastographic differences between cutoffs for primary and secondary hyperparathyroidism.

Objectives: It is believed that management of neonates with dextro-transposition of the great arteries is constantly improving. Renal function may play a role in the prognosis of patients after congenital heart surgery. The aim of this study was to describe the outcome of neonates who underwent arterial switch operation during the past 2 decades using renal function as a surrogate marker for morbidity and mortality., Design: Retrospective cohort study., Setting: Dedicated cardiac ICU of a university-affiliated pediatric medical center., Patients: Infants who underwent arterial switch surgery in 1993-2015., Interventions: None., Measurements and Main Results: The cohort included 336 infants who underwent arterial switch operation for dextro-transposition of the great arteries (n = 169, 50%), transposition of the great arteries/ventricular septal defect (n = 133, 40%), or Taussig-Bing anomaly (n = 34, 10%). Between 1993-1998 and 2012-2015, the mean minimal postoperative estimated glomerular filtration rate rose from 30 mL/min/1.73 m to 40 mL/min/1.73 m (p < 0.05), and the proportion of patients with estimated glomerular filtration rate less than 30 mL/min/1.73 m decreased from 56% to 23% (p < 0.05). The daily furosemide dosage decreased from 4 mg/kg/d to 0.5 mg/kg/d (p < 0.05). Urinary output on operative day 0 decreased over time, but urinary output on operative day 2 significantly increased. Maximal lactate levels and time to lactate normalization decreased steadily. Dialysis was performed in only a few patients in the early periods, and in none in the last 6 years. The mean mortality rate of patients with dextro-transposition of the great arteries and transposition of the great arteries/ventricular septal defect decreased to 2.7% in the last 6 years. The odds ratio of a prolonged hospital stay (≥ 28 d) in a patient with estimated glomerular filtration rate less than 30 mL/min/1.73 m was 18.79, and in a patient with transposition of the great arteries/ventricular septal defect, 3.39. The odds ratio of dying after Rashkind atrial septostomy was 4.42., Conclusions: During the past 2 decades, there has been significant improvement in outcome of patients undergoing transposition of the great arteries repair. Renal function was found to be a good prognostic marker of morbidity and mortality.

Background: Viral bronchiolitis caused by respiratory syncytial virus (RSV) is a common childhood disease accounting for many hospitalizations worldwide. Some infants may clinically deteriorate, requiring admission to an intensive care unit. We aimed to describe diagnostic and therapeutic measures of bronchiolitis in Israeli pediatric intensive care units (PICUs) and evaluate intercenter variability of care., Methods: Medical records of all RSV-infected infants admitted to 5 Israeli PICUs over 4 RSV seasons were retrospectively reviewed., Results: Data on 276 infants with RSV-positive bronchiolitis, admitted to the participating PICUs were analyzed. Most of the infants were males with a mean admission age of 4.7 months. Approximately half of the infants had pre-existing conditions such as prematurity, cardiac disease or chronic lung disease. Respiratory distress was the most common symptom at presentation followed by hypoxemia and fever. There was significant variation in the methods used for RSV diagnosis, medical management and respiratory support of the infants. Furthermore, utilization of inhalational therapy and transfusion of blood products differed significantly between the centers. Although a bacterial pathogen was isolated in only 13.4% of the infants, 82.6% of the cohort was treated with antibiotics., Conclusions: Significant variation was found between the different PICUs regarding RSV bronchiolitis diagnosis, medical management and respiratory support, which may not be accounted for by the differences in baseline and clinical characteristics of the infants. Some of these differences may be explained by uneven resource allocations. This diversity and the documented routine use of medications with weak evidence of efficacy calls for national guidelines for bronchiolitis management.

The shortage of dedicated pediatric extracorporeal membrane oxygenation (ECMO) centers and the expanding indications for pediatric ECMO necessitate a regional program for transport of ECMO-supported patients. Data about feasibly and safety of pediatric ECMO transport are scarce. Our aim is to describe our experience with a pediatric ECMO reach-out program and review pertinent literature. Demographic, clinical, and outcome data were collected retrospectively from the charts of all patients cannulated onto ECMO at referring centers and transported to our center from 2003 to 2018. Similar data were recorded for patients who were referred for ECMO support from within the hospital. The cohort included 80 patients cannulated at 17 referring centers. The transport team included a senior pediatric cardiac surgeon and an ECMO specialist. All transfers but one were done by special emergency medical service ambulance. No major complications or deaths occurred during transport, and all patients were stable upon arrival to our unit. Mortality was lower in the ECMO reach-out cohort than in-house patients referred for ECMO support. This is the first study from Israel and one of the largest to date describing a dedicated pediatric ECMO transport program. Extracorporeal membrane oxygenation transport appears to be feasible and safe when conducted by a small, highly skilled mobile team. Successful reach-out program requires open communication between the referring physician and the accepting center. As survival correlates with ECMO volume, maintaining a large ECMO center with 24/7 retrieval capabilities may be the best strategy for pediatric mechanical circulatory support program.

We sought to examine the role of preoperative and 2nd postoperative day albumin levels as predictors for postoperative course in infants undergoing repair of congenital heart disease. This retrospective, single-center, observational study comprised consecutive infants younger than 1 year who had undergone repair of tetralogy of Fallot, ventricular septal defect, complete atrioventricular canal or transposition of the great arteries over a 25 months period. We correlated preoperative and postoperative day (POD) #2 albumin level to vaso-inotropic score (VIS) and intensive care unit (ICU) length of stay (LOS) as markers for degree and duration of postoperative cardiac support. A composite outcome was defined as maximal vaso-inotropic score of > 10 and ICU LOS > 96 h. Preoperative albumin level negatively correlated with VIS and ICU LOS. Compared to preoperative albumin level of > 4 g/dL, the relative risk of meeting composite criteria was 1.5 for preoperative albumin of 3.1-4 g/dL and 2.6 for preoperative albumin ≤ 3 g/dL. Compared to POD#2 albumin level > 3 g/dL, the relative risk of meeting composite criteria was 1.8 for albumin of 2.6-3 g/dL, and 2.5 for albumin ≤ 2.5 g/dL. In summary, we found that preoperative and POD#2 albumin levels predicted prolonged and complicated postoperative course. These finding may help clinicians to inform the patient's parents, early in the ICU hospitalization, as to the predicted risks and difficulties of their infant's postoperative course.

Objectives: Chronic kidney disease is a rising cause of morbidity and mortality in developed countries, including end-stage renal disease (ESRD). The prevalence of thyroid comorbidities in persons with chronic kidney disease is documented higher than in normal population. The study aims to investigate the prevalence of morphological and functional thyroid disorders in patients with chronic kidney disease, with renal replacement therapy (hemodialysis)., Methods: A cross-sectional study was performed on 123 consecutive patients with chronic kidney disease stage 5, on hemodialysis during a period of one month (May 2019-June 2020). All patients were enrolled for maintenance hemodialysis in B Braun Hemodialysis Center Timisoara and were examined on conventional 2B ultrasound. Thyroid blood tests were done, including serum free thyroxin (FT4), free triiodothyronine (FT3) and thyroid-stimulating hormone (TSH) at the time of starting hemodialysis., Results: We evaluated 123 patients (male to female ratio 70/53) mean age 62.2 ± 11.01, mostly above 65 years old, enrolled in the end-stage renal disease program, on renal replacement therapy. From the cohort, 76/123 presented thyroid disease, including autoimmune hypothyroidism, nodular goiter or thyroid cancer. Among them, 63 patients presented nodular goiter, including 3 thyroid cancers, confirmed by surgery and histopathological result, 22 patients had thyroid autoimmune disease. The serum thyroid-stimulating hormone levels found in the cohort was 3.36 ± 2.313 mUI/mL, which was in the normal laboratory reference range. The thyroid volume was 13 ± 7.18 mL. A single patient in the cohort presented Graves Basedow disease, under treatment and three patients present subclinical hyperthyroidism. We have found that thyroid disease risk is increased by 3.4-fold for the female gender and also the increase of body mass index (BMI) with one unit raises the risk of developing thyroid disease with 1.083 times ( p = 0.018)., Conclusion: To conclude, this study aimed to quantify the prevalence of thyroid disease in end-stage kidney disease population, especially nodular goiter, important for differential diagnosis in cases with secondary hyperparathyroidism. Thyroid autoimmune disease can be prevalent among these patients, as symptoms can overlap those of chronic disease and decrease the quality of life. We have found that thyroid disease has a high prevalence among patients with end-stage renal disease on hemodialysis. Thyroid goiter and nodules in ESRD patients were more prevalent than in the general population. Clinical surveillance and routine screening for thyroid disorders can improve the quality of life in these patients.