Is preoperative balloon aortic valvuloplasty of interest for severe aortic stenosis in hip fracture surgery?

PurposeIn elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.MethodsWe conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.ResultsAmong the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).Conclusionspreoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.     

Trauma patients with tibia/fibula fractures are associated with an increased risk of torso,severe head,and severe spine injuries compared to patients with femur fractures

BackgroundAlthough previous studies have demonstrated an association between lower extremity fractures and concomitant torso (thorax and abdomen) injuries in trauma patients, they do not compare different types of fractures. Therefore, we investigated the risk of associated torso injuries between femur and tibia/fibula fractures, hypothesizing that trauma patients with femur fractures are at higher risk of torso injuries compared to patients with tibia/fibula fractures.MethodsThe Trauma Quality Improvement Program database (2010-2016) was queried for patients presenting with either femur or tibia/fibula fractures. Patients with ground-level falls and penetrating injuries were excluded. Univariable and multivariable logistic regression analyses were performed.ResultsFrom 162,354 patients, 104,075 (64.1%) patients had femur fractures and 58,279 (35.9%) had tibia/fibula fractures. Compared to those with femur fractures, patients with tibia/fibula fractures had a higher incidence of torso injuries (32.2% vs. 17.7%, p<0.001). The tibia/fibula fracture group was also associated with an increased risk of torso (OR 2.22, CI 2.17-2.27, p<0.001), severe (abbreviated injury scale grade > 3) head (OR 2.38, CI 2.30-2.46, p<0.001), and severe spine injuries (OR 2.33, CI 2.07-2.62, p<0.001) compared to the femur fracture group. Additionally, patients with tibia/fibula fractures had a higher rate of deep vein thrombosis (2.5% vs. 1.8%, p<0.001) than patients with femur fractures.ConclusionsContrary to previous studies, we demonstrate patients with tibia/fibula fractures have a higher associated risk of torso, severe head and severe spine injuries than patients with femur fractures. Therefore, trauma surgeons should manage tibia/fibula fracture patients with similar clinical vigilance as femur fracture patients.     

Pre-injury use of antiplatelet and anticoagulations therapy are associated with increased mortality in a cohort of 1038 hip fracture patients

BackgroundHip fractures are a large burden on the health care systems of developed nations. Patients usually have multiple co-morbidities and the pre-injury use of anticoagulants and anti-platelet medication is common.Materials and methodsThis study used a single hospital hip fracture database to facilitate a retrospective analysis of the impact of anti-coagulation and anti-platelet therapy on mortality and complications after surgical management of hip fractures. There were 92 patients on warfarin, 69 on DOAC, 260 antiplatelet patients and 617 control patients.ResultsMortality rates at 30 days were 4.8% for the control group, 12.6% for the antiplatelet group, warfarin 7.0%, 9.5% for Direct Oral Anticoagulant (DOAC) group, p = 0.004. Mortality rates at 1 year were 22.4% for the control group, 32.3% for the antiplatelet group, 29.3% for the warfarin group and 29.0% for DOAC group (p=0.007).Amongst complications, significant differences were found in transfusion (DOAC) and wound ooze (warfarin) rates, but the study did not detect significant clinical consequences arising from these differences.A matched analysis for age, sex, and ASA was undertaken to look in more detail at mortality data. Some mortality differences remained between groups with anti-platelet medication associated with increased mortality, but the differences no longer appeared to be significant.Our data suggests that this is a non-causal association, which could be incorporated into predictive mortality risk scores such as the Nottingham hip fracture score.ConclusionWe believe that pre-injury antiplatelet therapy is a strong indicator for high risk patients with higher expected mortality after hip fracture surgery. We saw no evidence to support delayed surgery in patients taking DOACs     

Infections after intramedullary fixation of trochanteric fractures are uncommon and implant removal is not usually needed

Background and purpose. Infections after intramedullary fixation of trochanteric femoral fractures are rare, but potentially life-threatening complications. There are limited data available to support decision making in these cases.Patients and methods. A retrospective study of 995 consecutive operatively treated trochanteric fractures was made to find out different risk factors for infection and to describe the results of treatment.Results. 28 patients developed a surgical site infection (2.8%) after intramedullary fixation of trochanteric fracture. 15 patients (1.5%) had a deep and 13 patients (1.3%) a superficial surgical site infection. Cigarette smoking (p<0.05) and prolonged operative time (p<0.05) were significant risk factors for an infection. 15 of 28 patients needed revision surgeries. Implant removal or exchange was needed only for 4 of 28 patients: 1 exchange of the blade, 1 removal of additional cable used to assist reduction and 2 removals of distal locking screws. None of the patients needed additional surgeries for problems with fracture healing. Mortality was not increased among patients with an infection.Interpretation. Infection after intramedullary fixation of trochanteric fractures can be successfully treated without removal or exchange of the fixation material.     

Evaluation of a chimeric multi-epitope-based DNA vaccine against subgroup J avian leukosis virus in chickens

The prokaryotic expressed recombinant chimeric multi-epitope protein X (rCMEPX) had been evaluated with good immunogenicity and protective efficacy against subgroup J avian leukosis virus (ALV-J) in our previous study. In the present research, we cloned the chimeric multi-epitope gene X into the eukaryotic expression vector pVAX1 to evaluate its potency as a DNA vaccine. The purified recombinant gp85 protein and rCMEPX were used as positive controls and a DNA prime-protein boost strategy was also studied. Six experimental groups of 7-day-old chickens (20 per group) were immunized intramuscularly three times at 2 weeks interval with PBS, gp85, rCMEPX, pVAX1, pVAX-X and pVAX-X + rCMEPX respectively. The antibody titers and cellular immune responses were assayed after immunization. The efficacy of immunoprotection against the challenge of ALV-J NX0101 strain was also examined. The results showed that the DNA vaccine could elicit both neutralizing antibodies and cellular responses. Immune-challenge experiments showed good protection efficacy against ALV-J infection. Particularly, the regimen involving one priming pVAX-X and twice recombinant rCMEPX boosting, induced the highest antibody titers in all immunized groups. Our results suggest that the constructed chimeric multi-epitope DNA has potential for a candidate vaccine against ALV-J when used in proper prime-boost combinations. The data presented here may provide an alternative strategy for vaccine design in chicken ALV-J prevention.     

宫腔镜取胚术在终止早早孕中的临床应用

目的:探讨宫腔镜取胚术终止早早孕的临床应用价值,寻找一种安全有效且并发症少的终止早早孕的流产方式。方法:随机选取134例早早孕患者,比较宫腔镜取胚术及传统人工流产术患者并发症(子宫穿孔,漏吸,不全流产,人工流产综合征,栓塞,术中出血量及感染等)的发生情况。结果:宫腔镜取胚术子宫穿孔、漏吸,不全流产发生率分别与对照组比较,均有统计学差异(P<0.05);人流综合征及感染的发生率与对照组比较差异无统计学意义。宫腔镜取胚术平均出血量明显少于对照组(P<0.05)。宫腔镜取胚术在手术同时发现妊娠合并黏膜下子宫肌瘤2例,合并子宫内膜息肉3例。结论:宫腔镜取胚术是一种安全、有效的终止早期妊娠的方法,尤其适合早早孕、合并子宫病变患者,在妇产科领域将有广阔的应用前景。     

MEASURING AMBULATION,MOTOR, AND BEHAVIORAL OUTCOMES WITH POST-STROKE FLUOXETINE IN TANZANIA: THE Phase II MAMBO TRIAL

We test the safety of fluoxetine post-ischemic stroke in Sub-Saharan Africa. Adults with acute ischemic stroke, seen <14 days since new-onset motor deficits, were enrolled from 11/2019– 10/2020 in a single-arm, open-label phase II trial of daily fluoxetine 20mg for 90 days at Muhimbili National Hospital, Dar es Salaam, Tanzania. The primary outcome was safety with secondary outcomes of medication adherence and tolerability. 34 patients were enrolled (11 female; mean age 52.2 years, 65% <60 years old; mean 3.3 days since symptom onset). Participants had hypertension (74%), diabetes (18%), and smoked cigarettes (18%). The median National Institutes of Health Stroke Scale score at enrollment was 10.5. The median Fugl Meyer Motor Scale score was 28.5 (upper extremity 8, lower extremity 17.5). 32/34 participants (91%) survived to 90 days. There were 8 serious and 2 non-serious adverse events. Deaths occurred due to gastrointestinal illness with low serum sodium (nadir 120 mmol/L) with seizure and gastrointestinal bleed from gastric cancer. The average sodium level at 90 days was 139 mmol/L (range 133–146) and alanine transaminase was 28 U/L (range 10–134). Fluoxetine adherence was 96%. The median mRS among survivors at 90 days was 2 and Fugl Meyer Motor Scale score was 66 (upper extremity 40, lower extremity 27). Median 90-day Patient Health Questionnaire-9 and Montgomery-Åsberg scores were 3.5 and 4 (minimal depression). Fluoxetine administration for 90 days post-stroke in Sub-Saharan Africa was generally safe and well-tolerated, but comorbid illness presentations were fatal in 2/34 cases, even after careful participant selection.     

Exploration of risk factors for hemoglobinuria and acute kidney injury following iliofemoral venous mechanical thrombectomy

ObjectiveTo evaluate the risk factors for hemoglobinuria and acute kidney injury (AKI) after percutaneous mechanical thrombectomy (MT) with or without catheter-directed thrombolysis (CDT) for iliofemoral deep vein thrombosis (IFDVT).MethodsPatients with IFDVT who had MT with the AngioJet catheter (group A), MT plus CDT (group B), or CDT alone (group C) from January 2016 to March 2020 were retrospectively evaluated. Hemoglobinuria was monitored throughout the treatment course, and postoperative AKI was assessed by comparing the preoperative (baseline) and postoperative serum creatinine (sCr) levels from the electronic medical records of all patients. AKI was defined as an elevation in the sCr level exceeding 26.5 ​μmol/L within 72 ​h after the operation according to the Kidney Disease Improving Global Outcomes criteria.ResultsA total of 493 consecutive patients with IFDVT were reviewed, of which 382 (mean age, 56 ​± ​11 years; 41% of them were females; 97 in group A, 128 in group B, and 157 in group C) were finally analyzed. Macroscopic hemoglobinuria was evident in 44.89% of the patients of the MT groups (101/225, 39 in group A, and 62 in group B), with no significant difference between the groups (P ​= ​0.219), but not in the patients in group C. None of the patients developed AKI (mean sCr difference −2.76 ​± ​13.80 ​μmol/L, range ​= ​−80.20 to 20.60 ​μmol/L) within 72 ​h after surgery.ConclusionsRheolytic MT is an independent risk factor for hemoglobinuria. A proper aspiration strategy, hydration, and alkalization following thrombectomy are particularly favorable for preventing AKI.