Data were collected of children admitted with ALF to 16 US pediatric liver transplant centers from 2008 to 2013 using the PHIS for a retrospective analysis of PALF trends. Patient data linked to the principal diagnosis code for acute necrosis of the liver (570.00) were analyzed for the following: demographics, regional differences, changes over time, pharmaceutical trends, procedural trends, associated diagnoses, and patient outcomes. In 52.5% of 583 patients who met the selection criteria for PALF, the etiology remained undetermined. Acetaminophen toxicity (18.7%) was the most common identifiable etiology, and hepatic encephalopathy (38.6%) was the most common complication. Mortality was lower than previously reported; 95.4% survived and 73.2% survived without a liver transplant. Acute respiratory failure (OR = 3.4, p = 0.035), acute kidney injury (OR = 3.6, p = 0.003), and cerebral edema (OR = 3.6, p = 0.02) were independently associated with increased risk of mortality. The use of N-acetylcysteine in non-acetaminophen-related ALF, the use of intracranial pressure monitoring, and the proportion of sepsis decreased significantly during the study period. The PHIS database can be a useful tool to study the future trends of PALF patients.
Prior studies have demonstrated positive impacts of antibiotic use on reducing mortality, rebleeding events, and length of hospitalization in adult cirrhotic patients with acute upper gastrointestinal bleeding (UGIB). We aimed to investigate the use of antibiotics in cirrhotic children with acute UGIB and its impact on patient outcomes. This was a retrospective study using the Pediatric Health Information System database. Cirrhotic patients aged 0 to 18 years with acute UGIB, admitted between October 2005 and September 2015, were identified based on ICD-9 codes. Patients with no documented endoscopy during admission were excluded. Forty-four (23 females) cirrhotic children were eligible for data analysis. The median patient age was 6 years. Etiology of acute UGIB included esophageal varices (n = 37), non-variceal bleeding (n = 4), and both (n = 3). A significant proportion of cirrhotic children with acute UGIB (n = 30, 68%) were given intravenous antibiotics within 48 hours of admission. Among children who did not develop bacteremia, 68% received antibiotics vs. 32% who did not ( P = .6). The rate of readmission within 30 days of discharge was 7% in patients with antibiotics vs. 21% in those without antibiotics ( P = .3). This study suggested that antibiotic use within 48 hours of admission in cirrhotic children with acute UGIB might have a positive impact on the percentage of children free of bacteremia and the readmission rate. A prospective study should investigate whether prophylactic antibiotics should be targeted only to a subgroup of cirrhotic children with acute UGIB who are particularly at high risk for bacterial infection.
rare and include worsening of demyelinating diseases, and neuropathies, often commencing months following treatment.to date. METHODS: We report the case of a 7 year old boy who was diagnosed with ulcerative colitis and primary sclerosing cholangitis at 6 and half years of age, who continued to have mild disease, manifested primarily by ongoing hematochezia and anemia despite Balsalazide and 6-Mercaptopurine therapy. His course to this point was unremarkable and his disease severity was mild with a Pediatric Ulcerative Colitis Score of 30. He was admitted for blood transfusion and underwent endoscopy and colonoscopy. He then received his first infusion of Infliximab. Other than mild sinus arrhythmia, he tolerated this well. There were no other notable events surrounding the infusion, he was interacting appropriately with normal vital signs and was discharged home. RESULTS: Within 6 hours of his infusion, he awoke from sleep from a severe headache and developed acute nausea and emesis. Half an hour later, he was slumped to one side and parents brought to a local emergency room. Upon arrival, he was completely unresponsive and emergently intubated. Given slight hypotension, he was suspected to have an anaphylactic reaction and received intravenous fluids, packed red blood cells and Epinephrine. Once transferred to our pediatric center, CT image of his brain revealed multifocal bilateral hypodense lesions with surrounding edema involving multiple lobes, the pons, and brainstem. Left sided lesions were largest and consistent with parenchymal hemorrhage. He was started on hypertonic saline and mannitol and external ventricular drains were promptly inserted, but his initial intracranial pressures were low. MRI imaging confirmed bilateral multi-territory infarcts that appeared to be arterial in nature without evidence of arterial clots, or venous infarcts. A workup for infectious encephalitis was negative, as was investigation for underlying anatomic anomalies of his vasculature. His presentation was not in keeping with an underlying vasculitis. An echocardiogram showed a dilated left ventricle, but did not show evidence of an arterial-septal defect, intracardiac thrombi or other abnormality. CONCLUSIONS: Our patient met criteria for brain death within 5 days following his single dose of Infliximab. Family refused an autopsy. We report a case of acute hemorrhagic stroke and ultimately fatal outcome following an initial infusion of Infliximab. Although the etiology of this event remains unclear, the close temporal relation to the Infliximab infusion cannot be ignored. To our knowledge, such a life threatening reaction within hours of Infliximab infusion has not been reported.
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