Short-Term Results of A Randomized Trial Comparing Remote Endarterectomy and Supragenicular Bypass Surgery for Long Occlusions of the Superficial Femoral Artery [The REVAS Trial]

ObjectiveTechniques for surgical repair of Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions of the superficial femoral artery (SFA) are supragenicular bypass grafting or the less invasive remote endarterectomy (RSFAE). This trial compares the patency rates of both techniques.DesignRandomized, multicenter trial.Materials and methods116 patients were randomized to RSFAE (n = 61) and supragenicular bypass surgery (n = 55). Indications for surgery were claudication (n = 77), rest pain (n = 21), or tissue loss (n = 18).ResultsMedian hospital stay was 4 days in the RSFAE group compared with 6 days in the bypass group (p = 0.004). Primary patency after 1-year follow-up was 61% for RSFAE and 73% for bypass (p = 0.094). Secondary patency was 79% for both groups. Subdividing between venous (n = 25) and prosthetic grafts (n = 30) shows a primary patency of 89% and 63% respectively at 1-year follow-up (p = 0.086).ConclusionRSFAE is a minimally invasive adjunct in the treatment of TASC C and D lesions of the SFA, with shorter admittance and a comparable secondary patency rate to bypass. The venous bypass is superior to both RSFAE and PTFE bypass surgery, but only 45% of patients had a sufficient saphenous vein available.This study is registered with ClinicalTrials.gov, number NCT00566436.     

Endovascular Repair of the Thoracic Aorta: Predictors of 30-Day Mortality in Patients on the New Zealand Thoracic Aortic Stent Database (NZ TAS)

ObjectivesTo evaluate data in the New Zealand Thoracic Aortic Stent database to try and identify a scoring system that could predict 30-day mortality in patients undergoing stenting of the descending thoracic aorta (TEVAR).DesignRetrospective analysis of the New Zealand thoracic aortic stent database between December 2001 and August 2007.Materials and methodsThe 30-day mortality of the 122 patients is 7.38% (n = 9). Risk factors were recorded based on the Society of Thoracic Surgeons (STS) risk score. Glasgow aneurysm score was calculated and the pathology being treated analysed. Univariate analyisis was carried out.ResultsThe mortality of three pathology groups was compared. 30-day mortality was 2.04% (n = 1) in the elective aneurysm group, 17.95% (n = 7) in the complicated Stanford type B dissection group, and 0% (n = 0) in the trauma group. Thirty-day mortality is significantly higher in the dissection group compared with the elective aneurysm (p = 0.02) and trauma (p = 0.03) groups. The most frequent risk factors in the dissection group of patients were peripheral vascular disease, smoking and hypertension. Although percentage mortality is higher with increasing GAS, the results are not statistically significant (p = 0.34). No independent risk factors were identified from the STS risk score data.ConclusionNo specific risk score system seems to be able to predict mortality in TEVAR patients.     

Treatment of shoulder calcifications of the cuff: A controlled study

ObjectivesAbout 1 in 10 patients with shoulder calcifications complains of chronic pain. Removal techniques have been developed. We carried out the first randomized study to validate bursoscopy (BS) and (needling fragmentation irrigation) (NFI) versus a control group (CT).Methods102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected using a corticosteroid; 49 shoulders improved by more than 70%. The other 53 shoulders were randomized in 3 groups: NFI (n = 16), BS (n = 20), and CT (n = 17). All patients were reviewed at T 1–4–12–24 months.ResultsAfter 4 months, we observed respectively in groups NFI – BS – CT: 62%, 65% and 29% patients showing global improvements >70% (NFI vs CT: p = 0.03; BS vs CT: p = 0.02); ?37%, ?29% and ?11% pain VAS variation (ns), +16%, +12% and ?15% Constant score variation (NFI vs CT: p = 0.03; BS vs CT: p = 0.02), and ?58%, ?77% and +4% area calcification variation (NFI vs CT: p = 0.005; BS vs CT: p = 0.0002; BS vs NFI: p = 0.01). After 24 months, results were maintained in NFI and BS groups, and in the CT group only 6/17 patients were still improved. There were no significant differences between NFI and BS groups. Three partial tears of the cuff were found using MRI in failures, (1 in each group).ConclusionNFI and BS are now validated removal techniques of shoulder calcifications when there is chronic pain and other medical treatments have failed. Results were maintained after 24 months, and were similar between NFI and BS. However NFI could be preferred because of its simplicity and low cost.     

An Emergency EVAR Service Reduces Mortality in Ruptured Abdominal Aortic Aneurysms

ObjectivesThe aim of this study was to compare all in-hospital mortality for ruptured abdominal aortic aneurysms (rAAAs) before and after the establishment of an emergency EVAR (eEVAR) service.Design and methodsAn eEVAR service was established in January 2006, since when all patients presenting with rAAAs have been considered for endovascular repair. Data for all rAAAs presenting between January 2006 and December 2007 was prospectively collected (Group 1). This patient group was compared to those presenting with rAAA between January 2003 and December 2005 when eEVAR was not offered at our institution (Group 2). These records had also been collected prospectively and submitted to the National Vascular Database (NVD).ResultsA total of 50 rAAAs (17 eEVAR, 29 open repairs, 4 palliated) presented after the introduction of eEVAR (Group 1) and 71 in the historical Group 2 of which 54 underwent open repair and 17 were palliated. The total in-hospital mortality was significantly lower in Group 1 20% (eEVAR (n = 1), 6%: Open (n = 5), 17%: palliated (n = 4), 100%) when compared to Group 2 54% (Open (n = 21), 39%: palliated (n = 17), 100%) (p = 0.000001). Furthermore similar significant differences were seen in 30-day operative mortalities between the two groups 13% in Group 1 versus 39% in Group 2 (p = 0.0003). In addition the proportion of patients who were palliated has significantly decreased (8% Group 1 versus 24% Group 2, p = 0.01).ConclusionsThe establishment of an eEVAR service has significantly reduced in-hospital mortality for patients presenting with ruptured abdominal aortic aneurysms.     

Omitting pre-operative coagulation screening tests in hip fracture patients: Stopping the financial cascade?

BackgroundCoagulation screening continues as a standard of care in many hip fracture pathways despite the 2011 guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which recommend that such screening be performed only if clinically indicated. This study aims to evaluate the use of pre-operative coagulation screening and explore its financial impact.MethodsProspective data was collected in accordance with the “Standardised Audit of Hip Fractures in Europe” (SAHFE) protocol. All patients admitted to our hospital with hip fractures during a 12-month period from November 2011 to November 2012 were analysed. Data including coagulation results and the use of vitamin K or blood products were collected retrospectively from the hospital computer system. Patient subgroup analysis was performed for intraoperative blood loss, post-operative blood units transfused, haematoma formation and gastrointestinal haemorrhage.Results814 hip fractures were analysed. 91.4% (n = 744) had coagulation tests performed and 22.0% (n = 164) had an abnormal result. Of these, 55 patients were taking warfarin leaving 109 patients who had abnormal results and were not taking warfarin. When this group (n = 109) was compared to those who had normal test results (n = 580) and to all other patients (n = 705) there was no difference in intraoperative blood loss (p = 0.79, 0.78), postoperative transfusion (p = 0.38, 0.30), postoperative haematoma formation (p = 0.79, 1.00), or gastrointestinal haemorrhage (p = 0.45, 1.00), respectively. In those who were not taking warfarin, but had abnormal results, none had treatment to reverse their coagulopathy with either vitamin K or blood products. By omitting pre-operative coagulation tests in patients who are not taking warfarin, we estimate a financial saving of between £66,500 and £432,250 per annum.ConclusionsThis study supports the hypothesis that routine pre-operative coagulation screening is unnecessary in hip fracture patients unless they take warfarin or have a known coagulopathy. Moreover, its omission represents significant cost-saving potential.     

Long-term follow-up of trauma patients before and after implementation of a physician-staffed helicopter: A prospective observational study

IntroductionThe first Danish Helicopter Emergency Medical Service (HEMS) was introduced May 1st 2010. The implementation was associated with lower 30-day mortality in severely injured patients. The aim of this study was to assess the long-term effects of HEMS on labour market affiliation and mortality of trauma patients.MethodsProspective, observational study with a maximum follow-up time of 4.5 years. Trauma patients from a 5-month period prior to the implementation of HEMS (pre-HEMS) were compared with patients from the first 12 months after implementation (post-HEMS). All analyses were adjusted for sex, age and Injury Severity Score.ResultsOf the total 1994 patients, 1790 were eligible for mortality analyses and 1172 (n = 297 pre-HEMS and n = 875 post-HEMS) for labour market analyses. Incidence rates of involuntary early retirement or death were 2.40 per 100 person-years pre-HEMS and 2.00 post-HEMS; corresponding to a hazard ratio (HR) of 0.72 (95% confidence interval (CI) 0.44–1.17; p = 0.18). The HR of involuntary early retirement was 0.79 (95% CI 0.44–1.43; p = 0.43). The prevalence of reduced work ability after three years were 21.4% vs. 17.7%, odds ratio (OR) = 0.78 (CI 0.53–1.14; p = 0.20). The proportions of patients on social transfer payments at least half the time during the three-year period were 30.5% vs. 23.4%, OR = 0.68 (CI 0.49–0.96; p = 0.03). HR for mortality was 0.92 (CI 0.62–1.35; p = 0.66).ConclusionsThe implementation of HEMS was associated with a significant reduction in time on social transfer payments. No significant differences were found in involuntary early retirement rate, long-term mortality, or work ability.     

Assessment of calcific tendonitis of rotator cuff by ultrasonography: Comparison between symptomatic and asymptomatic shoulders

ObjectiveCalcific tendonitis of rotator cuff is observed on plain radiographs in 10% of adults, but remains asymptomatic in half these cases. We looked for differences on ultrasound (US) and power Doppler findings between symptomatic and asymptomatic cases of shoulder calcific tendonitis.MethodsUS was performed in 62 patients (81 shoulders) with symptomatic (n = 57) or asymptomatic (n = 24) calcific tendonitis. Calcific plaque morphology, power Doppler signaling, and widening of the subacromial-subdeltoid bursa (SSB) were recorded. US-guided steroid injection into the SSB (n = 21) or needle puncture of calcific deposits (n = 29) was performed at the end of US evaluation in 50 of the 57 patients, and a questionnaire was sent to each patient after 11 ± 6 months.ResultsLarger (p = 0.0015) and fragmented (p = 0.01) calcifications were associated with pain. A power Doppler signal and a widening of the SSB was identified in 21 and 17 of the 57 symptomatic calcification respectively, but in none of the cases of asymptomatic calcification (p < 0,005). At least one of these signs was present in 31 of the 57 (54%) symptomatic shoulders (p < 0.001). Long-term outcome was favourable for 60% of our patients after steroid injection. The presence of a SSB widening before bursal steroid injection was associated with an improvement of the symptoms (p = 0.06).ConclusionPositive power Doppler signal within the calcific deposit and SSB widening are US features strongly associated with pain. Moreover, larger calcifications are also more symptomatic. According to these results, US can help physicians to confirm that calcification is responsible for shoulder pain.     

Treadmill versus overground gait training in patients with lower limb burn injury: A matched control study

IntroductionGait impairment is commonly seen in patients with a lower limb burn injury (LLBI). Therefore, the aim of this study was to investigate the effects of two different gait training modes on gait symmetry, functional mobility and kinesiophobia in patients with LLBI.MethodsThis matched control study was conducted between January 2017 and August 2018. Patients with LLBI (n = 28) were allocated to 2 different groups by matching according to burn localization, age, and gender. Group 1 (overground group: n = 14) received overground gait training in addition to standard burn rehabilitation, and Group 2 (treadmill group: n = 14) received treadmill gait training in addition to standard burn rehabilitation. The rehabilitation program and gait training were started when the patient was admitted to the hospital and ended on discharge. These physical therapy interventions were performed 5 days per week. The gait training intensity, including walking speed and duration, was determined according to patient tolerance. Gait parameters, functional mobility, kinesiophobia and pain values were evaluated with GAITRite, the timed up-and-go test (TUG), Tampa Kinesiophobia Scale and Visual Analogue Scale, respectively. These evaluations were made twice; on admission and immediately prior to discharge. Gait symmetry was calculated using the Symmetry Index.ResultsThe baseline characteristics of the groups and initial outcome values were similar. In the comparison of the differences between the overground and treadmill groups, the change in kinesiophobia and TUG values were significantly higher in the treadmill group (p = 0.01, p = 0.02, respectively). The intragroup comparisons showed significant differences in SI in respect of step length (p = 0.004), swing (p = 0.006), stance (p = 0.008) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the overground group. Statistically significant differences were determined in step length (p = 0.01), swing (p = 0.01), stance (p = 0.02) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the treadmill group, when pre and post-training values were compared.ConclusionsThe results of this study have shown that treadmill gait training was more effective in the improvement of functional mobility and reduction in kinesiophobia levels of patients with LLBI compared to overground gait training. Both overground and treadmill gait training also provide greater improvements in the velocity and cadence, and gait symmetry for step length, swing and stance in patients with LLBI.Clinical trial registration numberNCT03217526.     

Comparação entre dois dispositivos supraglóticos de vias aéreas na dor de garganta pós‐operatória em crianças: estudo controlado prospectivo randomizado

Background and objectiveSore throat is well recognized complaint after receiving general anesthesia. This study is conducted to compare the severity and frequency of postoperative sore throat in children undergoing elective surgery – following the use of Ambu laryngeal mask airway) or I‐gel® – who are able to self‐report postoperative sore throat.MethodSeventy children, 6 to 16 years‐old, undergoing elective surgery randomly allocated to either Ambu laryngeal mask (Ambu Group) or I‐gel® (I‐gel Group). After the procedure, patients were interviewed in the recovery room immediately, after one hour, 6 and 24 hours postoperatively by an independent observer blinded to the device used intra‐operatively.ResultsOn arrival in the recovery room 17.1% (n = 6) of children of the Ambu Group complained of postoperative sore throat, against 5.7% in I‐gel Group (n = 2). After one hour, the results were similar. After 6 hours, postoperative sore throat was found in 8.6% (n = 3) of the children in Ambu group vs. 2.9% (n = 1) in I‐gel Group. After 24 hours, 2.9% (n = 1) of the kids in Ambu Group compared to none in I‐gel Group. There was no significant difference found in the incidence of postoperative sore throat in both devices on arrival (p = 0.28); after 1 hour (p = 0.28); after 6 hours (p = 0.30); and after 24 hours (p = 0.31). The duration of the insertion was shorter in Ambu Group and it was easier to insert the I‐gel® (p = 0.029). Oropharyngeal seal pressure of I‐gel® was higher than that of Ambu laryngeal mask (p = 0.001).ConclusionThe severity and frequency of postoperative sore throat in children is not statistically significant in the I‐gel Group compared to Ambu Group.     

Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation

ObjectiveTo elucidate the risk factors associated with amputation in cases with combat-related vascular injury (CRVI).Material and methodsThis retrospective study included 90 cases with CRVI treated between May 2011 and July 2013. The patients were divided into group I (n = 69), in which the limb was salvaged and group II (n = 21), in which the patients received amputation.ResultsThe overall and the secondary amputation rates were 23% and 18%, respectively. There were no amputations with the MESS of nine or less, increasing proportions of amputations at 10 and 11, with a level of 12 leading to 100% amputation rate. The mortality rate was 2%. Among the 52 (58%) cases with the mangled extremity severity score (MESS) ≥ 7, the limb salvage rate was 60%. The patients in group II were more likely to have a combined artery and vein injury (p = 0.042). They were also more likely to be injured as a result of an explosion (p = 0.004). Along with the MESS (p < 0.001), the duration of ischemia (DoI) (p < 0.001) were higher in group II. The rate of bony fracture (p < 0.001) and wound infection (p = 0.011) were higher in group II. For the overall amputation, the odds ratio of the bony fracture (OR: 61.39, p = 0.011), nerve injury (OR: 136.23, p = 0.004), DoI (OR: 2.03, p = 0.003), vascular ligation (OR: 8.65, p = 0.040) and explosive device injury (OR: 10.8, p = 0.041) were significant. Although the DoI (p < 0.001) and the MESS (p = 0.004) were higher in whom a temporary vascular shunt (TVS) was applied, the utilisation of a TVS did not influence the amputation rate (p = 1.0).ConclusionsThe DoI and the variables indicating the extent of tissue disruption were the major determinants of amputation. While statistically non-significant, the benefit of the application of a TVS is non-negligible. MESS is a valid scoring system but should not be the sole foundation for deciding on amputation. Extremities which were doomed to amputation with the MESS >7 seem to benefit from revascularisation with initiation of reperfusion at once. The validity of MESS merits further investigation with regard to the determination of a new cut-off value under ever developing medical management strategies.     

Peribulbar versus sub-Tenon block in cardiac patients undergoing cataract surgery during warfarin therapy

ObjectiveTo compare sub-Tenon’s block with peribulbar block in patients on oral warfarin therapy undergoing cataract surgery.Materials and methodsWe studied 100 patients on warfarin undergoing cataract surgery; randomly allocated into one of two groups; sub-Tenon’s group (group S, n = 50), and peribulbar group (group P, n = 50). In group (S), sub-Tenon’s injection of 3–5 ml of anesthetic agent was done using a 25 mm sub-Tenon’s cannula. In group (P), the peribulbar block with 3–4 ml of 2% lidocaine–hyaluronidase (10 IU/ml) and 0.5% bupivacaine was done. Pain and akinesia and postoperative complications were assessed.ResultsSub-Tenon group showed significantly higher frequency of hemorrhage compared to peribulbar group (30% versus 8%, p = 0.041), mainly of grade I. The two groups had comparable frequency of subconjunctival hemorrhage (p = 1.000). No patients experienced sight-threatening hemorrhagic complications. Pain was significantly lower in the sub-Tenon group. Akinesia was significantly better (p = 0.025) 2 min after injection and comparable from 4 to 10 min after injection in the peribulbar group. The majority of patients in the two groups reported satisfaction (p = 0.372). The surgeon expressed higher satisfaction with peribulbar block (94%) compared to sub-Tenon’s block (81%) (p = 0.064).ConclusionPeribulbar and sub-Tenon techniques were relatively safe in patients on anticoagulants during cataract operation. We recommend peribulbar technique owing to significantly less bleeding and more satisfactory akinesia response and hence surgeon comfort.     

Randomised Controlled Trial Comparing Sapheno-Femoral Ligation and Stripping of the Great Saphenous Vein with Endovenous Laser Ablation (980 nm) Using Local Tumescent Anaesthesia: One Year Results

ObjectivesComparison of sapheno-femoral ligation and stripping (SFL/S) versus endovenous laser ablation (EVLA, 980-nm) in the treatment of great saphenous vein (GSV) insufficiency, using local tumescent anaesthesia.DesignRandomised, single centre trial.Materials and methodsPatients with GSV incompetence and varicose veins were randomised to either SFL/S or EVLA. At days 1, 2, 3, 7, 10, and 14 post-treatment, patients completed questionnaires on pain and quality of life. Recurrent varicose veins were evaluated by Duplex ultrasound (DUS) performed at 1 and 6 weeks, and 6 and 12 months.Results130 legs in 121 patients were treated by SFL/S (n = 68) or EVLA (n = 62). Significantly more post-treatment pain was noted after EVLA at days 7, 10 and 14 (p < 0.01; p < 0.01; p = 0.01), more hindrance in mobility at days 7 (p < 0.01) and 10 (p = 0.01), and in self care (p = 0.03) and daily activities (p = 0.01) at day 7 compared to SFL/S. DUS at 1-year follow-up showed 9% recurrences (5/56) after EVLA and 10% (5/49) after SFL/S.ConclusionBoth SFL/S and EVLA, using local tumescent anaesthesia, were well tolerated, with no difference in short-term recurrence rate. In the second week after EVLA, patients experienced significantly more pain resulting in restricted mobility, self care and daily activity compared to SFL/S.     

Transplacental transfer and neonatal influences of sonophoretically administered sufentanil versus epidural sufentanil in labor peridural analgesia: A randomized prospective double-blind contemplate

BackgroundLabor sufentanil impact on the newborn is debatable. This randomized double-blind investigation examined the transplacental conveyance and neonatal influences of sonophoretic versus epidural sufentanil for labor analgesia and its outcome on breast-feeding.Methods60 Healthy parturient women receiving labor epidural analgesia were enrolled in the study. They were administered epidural bupivacaine (12-ml bolus then 10 ml/h of 0.125%) solely (Group I, n = 20) or with sonophoretically transdermally administered sufentanil (Group II, n = 20) or with epidurally administered sufentanil (Group III, n = 20). Sufentanil received by Groups II and III was 15 μm followed by 10 ml/h of 0.25 μm/ml solution.ResultsSufentanil was detected in five umbilical arterial (UA) samples in Group III versus in two UA samples in Group II. Neonatal Neurologic and Adaptive Capacity Score (NACS) at 24 h was lowest in Group III (P = 0.04). On postpartum day 1, Group III women reported breast-feeding difficultly (25%) more oftentimes than Group II women (10%), or Group I women (5%) (P = 0.05). There was 45% breast-feeding difficulty in each group according to lactation consultant’s assessment (P = 1.0). At 6 weeks postpartum, more Group III women were not breast-feeding (35%) than Group II women (10%) or Group I (10%) (P = 0.004).ConclusionSufentanil transplacental transport and fetal exposure appeared greater in epidural than in sonophoretic sufentanil. The former group women were facing more difficulty at starting breast-feeding on postpartum day 1 and were more apt to have stopped breast-feeding 6 weeks postpartum than the latter group women.     

The impact of serum albumin and serum protein levels on POSSUM score of patients with proximal femur fractures

BackgroundPOSSUM was developed to predict risk-adjusted mortality and morbidity rates for surgical procedures. We evaluated the impact of serum albumin and serum protein levels on POSSUM scores.MethodsMedical files of 2269 patients operated for proximal femur fractures were reviewed. Preoperative serum albumin levels were available for 387 patients (mean 35.1 g/l, range 22–49) and serum protein levels for 279 patients (mean 61.6 g/l, range 40–86).ResultsSerum albumin and protein levels were inversely associated with mortality in multivariate models (albumin, OR = 0.89, p = 0.009; protein, OR = 0.92, p = 0.009) and in composite outcome models as well (albumin, OR = 0.955, p = 0.219, protein, OR = 0.94, p = 0.014). The area under the curve (AUC) for POSSUM prediction of mortality (n = 1770) was 0.632 (95% CI: 0.580–0.684, p < 0.001). The AUC for a model including serum protein levels was 0.742 (95% CI: 0.649–0.834, p < 0.001). Hospitalisation time was longer for patients with lower serum proteins levels (p = 0.045), with an inverse correlation (Pearson correlation −0.164, p = 0.011).ConclusionsLower preoperative serum albumin and serum protein levels were associated with increased risk for mortality, increased hospitalisation time and poorer outcomes in patients operated for proximal femoral fractures. Including those values to POSSUM scores would increase their predictive power.     

Clinical and Angiographic Follow-up of Spontaneous Isolated Superior Mesenteric Artery Dissection

ObjectivesTo observe the clinical features and angiographic findings in patients with a spontaneous isolated superior mesenteric artery dissection (SISMAD) and to identify any correlation between them.MethodsFrom a single institution, 32 patients (22 symptomatic patients at presentation; mean age 54 years; men 97%) with SISMAD were retrospectively reviewed. All patients were available for clinical follow-up after treatment (conservative, n = 28, 88%, open or endovascular superior mesenteric artery (SMA) reconstruction, n = 4, 12%), and follow-up CT scans were available in 28 patients (mean 22 months, range 1–80 months).ResultsWe found a positive correlation between pain severity and dissection length (p = 0.03, ρ = 0.50, Spearman's partial correlation analysis). After conservative treatment, only one patient (3%) required bowel resection, and there was no difference in outcome between patients who were treated with anticoagulation or anti-platelet therapy and those who were not (p = 1.00, Fisher's exact test). No patients had progression of their lesion on the follow-up CT angiography.ConclusionsIn SISMAD patients, dissection length is positively associated with more severe clinical symptoms. After conservative treatment, we observed a benign clinical course and no CT progression of the dissection, even without anticoagulation or anti-platelet therapy. Based on our observation, patients with SISMAD can be treated conservatively without anticoagulation therapy.     

Embolización vesical supraselectiva versus formalina intravesical para la hematuria intratable en pacientes con cáncer de vejiga

ObjectiveIntractable hematuria is a leading critical problem occurring in patients with advanced stage bladder cancer (BCa) that are not suitable for radical cystectomy. The present study, for the first time in the literature, aimed to compare the effectiveness of intravesical formalin (IF) and superselective vesical artery embolization (SVAE) in the management of intractable and life-threatening hematuria in BCa patients.MethodsThe retrospective study included 40 BCa patients who underwent SVAE or IF treatment due to intractable hematuria after failure of other methods. Patients were divided into two groups based on the procedures administered: SVEA Group (n = 24) and IF Group (n = 16).ResultsThe success rate at first-line therapy was 50% (12/24) in SVAE Group and 82% (13/16) in IF Group (p = 0.046). Based on the success rates at first- and second-line therapies, the overall success rate in SVAE Group was 75% and this rate was similar to that of IF Group (p = 0.439). Complication rate was significantly higher in IF patients than in SVAE patients (37.5% vs. 8.3; p = 0.024), whereas duration of postoperative hospital stay was significantly longer in SVAE Group (15.8 vs. 6 days; p = 0.041).ConclusionThe advantages of IF appear to include shorter postoperative hospital stays and higher success rates at a single session, while the advantages of SVAE seem to include non-requirement of spinal/general anesthesia, easy repeatability, and low complication rates. In the management of patients with intractable hematuria, patients’ general condition, comorbidities, and anesthesia-related risks should be taken into consideration.     

Polymorphisms in inflammation associated genes ALOX15 and IL-6 are associated with bone properties in young women and fracture in elderly

PurposeALOX12 and ALOX15 encode arachidonate lipoxygenases which produce lipid metabolites involved in inflammatory processes. Metabolites generated by ALOX12 and ALOX15 can activate the expression of the potent pro-inflammatory cytokine IL-6, and produce endogenous ligands for PPARG. In this study, polymorphisms in ALOX12, ALOX15, IL6 and PPARG were investigated for association with bone properties in young and elderly Swedish women.MethodsThree SNPs in ALOX12, five in ALOX15, one each in IL6 and PPARG were genotyped in the cohorts PEAK-25 (n = 1061 women; all 25 y) and OPRA (n = 1044 women; all 75 y). Bone mineral density (BMD) and quantitative ultrasound (QUS) were analyzed in both cohorts; trabecular bone score (TBS) in PEAK-25; bone loss, fracture incidence and serum C-reactive protein (CRP) were assessed in OPRA.ResultsIn the elderly women ALOX15 (rs2619112) was associated with CRP levels (p = 0.004) and incident fracture of any type (p = 0.014), although not with BMD or ultrasound. In young women, carrying the common T allele (ALOX 15 rs748694) was associated with lower QUS values (p = 0.002–0.006). The IL6 SNP was associated with lower BMD in PEAK-25 (femoral neck p = 0.034; hip p = 0.012). TBS was not associated with variation in any gene. Variants in the ALOX12 and PPARγ were not associated with BMD in either cohort.ConclusionsThis study suggests that variation in inflammation related genes ALOX15 and IL6 was associated with bone microarchitecture and density in young adult women, but appears to be less important in the elderly, despite an observed association with CRP as a marker of inflammation and incident fracture.     

Blunt splenic injury: Outcomes of proximal versus distal and combined splenic artery embolization

PurposeTo assess clinical outcomes of blunt splenic injuries (BSI) managed with proximal versus distal versus combined splenic artery embolization (SAE).Materials and methodsAll consecutive patients with BSI admitted to our trauma centre from 2005 to 2010 and managed with SAE were reviewed. Outcomes were compared between proximal (P), distal (D) or combined (C) embolization. We focused on embolization failure (splenectomy), every adverse events occurring during follow up and material used for embolization.ResultsFifty patients were reviewed (P n = 18, 36%; D n = 22, 44%; C n = 8, 16%). Mean injury severity score was 20. The technical success rate was 98%. Four patients required splenectomy (P n = 1, D n = 3, C n = 0). Clinical success rate for haemostasis was 92% (4 re-bleeds: P n = 2, D n = 2, C n = 0). Outcomes were not statistically different between the materials used. Adverse events occurred in 65% of the patients during follow up. Four percent of the patients developed major complications and 56% developed minor complications attributable to embolization. There was no significant difference between the 3 groups.ConclusionSAE had an excellent success rate with adverse events occurring in 65% of the patients and no significant differences found between the embolization techniques used. Proximal preventive embolization appears to protect in high-grade traumatic injuries.