Agreement in Endovascular Thrombolysis Patient Selection Based on Interpretation of Presenting CT and CT-P Changes in Ischemic Stroke Patients

Background

To evaluate the agreement in patient selection based on computed tomography (CT) and CT-perfusion (CT-P) imaging interpretation between stroke specialists in stroke patients considered for endovascular treatment.

Methods

All endovascular-treated acute ischemic stroke patients were identified through a prospective database from two comprehensive stroke centers; 25 consecutively treated patients were used for this analysis. Initial CT images and CT-P data were independently interpreted by five board eligible/certified vascular neurologists with additional endovascular training to decide whether or not to select the patient for endovascular treatment. The CT/CT-P images were evaluated separately and used as the sole imaging decision making criteria, 2?weeks apart from each other (memory wash-out period). For each set of imaging data inter-rater and intra-rater agreement scores were obtained using Cohen??s kappa statistic to assess the proportion of agreement beyond chance.

Results

Kappa values for the treatment decisions based on CT images was 0.43 (range 0.14?C0.8) (moderate agreement), and for the decisions based on CTP images was 0.29 (range 0.07?C0.67) (fair agreement) among the five subjects. There was substantial variability within the group and between images interpretation. Observed agreement on decision to treat with endovascular therapy was found to be 75% with CT images and 59% with CT-P images (with no adjustment for chance). Kappa values for intra-rater agreement were ?0.14 (ranged ?0.27?C0.27) (poor agreement).

Conclusions

There is considerable lack of agreement, even among stroke specialists, in selecting acute ischemic stroke patients for endovascular treatment based on CT-P changes. This mandates a careful evaluation of CT-P for patient selection before widespread adoption.     

Cost-Effectiveness of the Management of Rh-Negative Pregnant Women

ObjectiveThe purpose of this study was to determine the most cost-effective option to prevent alloimmunization against the Rh factor.MethodsA virtual population of Rh-negative pregnant women in Quebec was built to simulate the cost-effectiveness of preventing alloimmunization. The model considered four options: (1) systematic use of anti-D immunoglobulin; (2) fetal Rh(D) genotyping; (3) immunological determination of the father’s Rh type; (4) mixed screening: immunological determination of the father’s Rh type, followed if positive by fetal Rh(D) genotyping. Two outcomes were considered, in addition to the estimated costs: (1) the number of babies without hemolytic disease, and (2) the number of surviving infants.ResultsIn a first pregnancy, two options emerged as the most cost-effective options: systematic prophylaxis and immunological Rh typing of the father, with overlapping confidence intervals between them. In a second pregnancy, the results were similar. In all cases (first or second pregnancy or a combination of the two) fetal genotyping was not found to be a cost-effective option.ConclusionRoutine prophylaxis and immunological Rh typing of the father are the most cost-effective options for the prevention of Rh alloimmunization. Considering that immunological typing of the father would probably not be carried out by the majority of clinicians, routine prophylaxis remains the preferred option. However, this could change if the cost of Rh(D) fetal genotyping fell below $140 per sample.     

Is Patient Satisfaction After Total Knee Arthroplasty Predictable Using Patient Characteristics and Preoperative Patient-Reported Outcomes?

BackgroundDissatisfaction after total knee arthroplasty (TKA) remains a difficult problem. Patient characteristics and preoperative patient-reported outcomes (PROs) are potential predictors of satisfaction one year after TKA. Being able to predict the outcome preoperatively might reduce the number of less satisfied patients.MethodsA retrospective cohort study on prospectively collected data of 1239 primary TKA patients (ASA I-II, BMI <35) was performed. Primary outcome was degree of patient satisfaction one year after TKA (Numeric Rating Scale (NRS) 0-10). Secondary outcomes were degree of patient satisfaction six months and two years after TKA and being dissatisfied (NRS 0-6) or satisfied (NRS 7-10) at all three time points. Multivariate linear and binary logistic regression analyses were executed with patient characteristics and preoperative PROs as potential predictors.ResultsOne year after TKA, median NRS satisfaction score was 9.0 (8.0-10.0) and 1117 (90.2%) patients were satisfied. BMI, degree of medial cartilage damage, previous knee surgery, Knee injury and Osteoarthritis Outcome Score-Physical Function Short Form score, EQ VAS score, and anxiety were identified as predictors of the degree of patient satisfaction (P = .000, R² = 0.027). Models on secondary outcomes reported R² of 1.7%-7.1% (P < .05). All models showed bad agreement between observed and predicted values for lower NRS satisfaction scores and being dissatisfied.ConclusionThe degree of patient satisfaction and the chance of being dissatisfied or satisfied six months, one, and two years after TKA are predictable by patient characteristics and preoperative PROs but not at a reliability level that is clinically useful.     

Right Colectomy with Absorbable Mesh Repair as a Salvage Solution for the Management of Giant Incisional Hernia with Loss of Domain: Results of a Bicentric Study

Background

Incisional hernia (IH) may occur in 20% of patients after laparotomy. The hernia sac volume may be of significance, with reintegration of visceral contents potentially leading to repair failure or abdominal compartment syndrome. The present study aimed to evaluate a two-step surgical strategy comprising right colectomy for hernia reduction with synchronous absorbable mesh repair followed by definitive non-absorbable mesh repair in recurrence.

Methods

Patients operated between 2012 and 2017 at two university centers were retrospectively included. Volumetric evaluation of the IH was performed by CT imaging.

Results

Eleven patients were included. The mean BMI was 43 kg/m² (23–52 kg/m²). Progressive preoperative pneumoperitoneum was performed in 82% of patients, with complications in 22%. The mean volumetric ratio of the volume of the hernia to the volume of the abdominal cavity was 70% (48–100%). The first parietal repair was performed using an synthetic absorbable mesh (36%), a biologic mesh (27%), or a slowly absorbable mesh (36%). No patients died as a result of the procedure. Seven (64%) patients developed grade III–IV complications, including one case of an anastomotic fistula. Recurrence occurred in eight (73%) patients after the first repair. Of these, four (50%) patients were reoperated using a non-absorbable mesh, leading to solid repair in 75% of cases. After 27 ± 18 months of follow-up, the residual IH rate was 46%.

Conclusions

Right colectomy for volume reduction in IH with loss of domain potentially represents an appropriate salvage option, supporting bowel reintegration and temporary hernia repair with absorbable material.

     

Genetics and epidemiology of Wilms' tumor: The French Wilms' tumor study

A complete family history was obtained for 501 patients with Wilms' tumor, treated in departments of pediatric oncology in whole France. The information was collected by self-questionnaire and/or by interview of parents. The proportion of bilateral cases is 4.6% and there are 12 patients (2.4%) with a positive family history of Wilms' tumor. The affected relatives are most often distant and no first degree relative was affected. Apart from the well-known associations with aniridia, hemihypertrophy, genitourinary anomalies, Beckwith-Wiedeemann, and Drash syndromes, there is also a significant excess of congenital heart defects (P = .008) which remains to be explained. Several findings support the bimutational hypothesis such as earlier diagnosis and increased parental age in bilateral cases. No particular anomalies and no increased frequency of childhood cancer were found in patients' relatives. The frequency of Wilms' tumor in relatives was estimated to be less than 0.4% in sibs, 0.06% in unclesand aunts, and 0.04% in first cousins. These figures are very different from those found in retinoblastoma and suggest that the mechanism may be more complex in Wilms' tumor. This conclusion is in agreement with molecular biology studies in tumors and linkage analysis in multiple case families which suggest that more than one locus is involved. © 1992 Wiley-Liss, Inc.     

Illness-related behaviour and utilization of oral health services among adult city-dwellers in Burkina Faso: evidence from a household survey

Background  

In sub-Saharan Africa, the availability and accessibility of oral health services are seriously constrained and the provision of essential oral care is limited. Reports from the region show a very low utilization of oral health care services, and visits to dental-care facilities are mostly undertaken for symptomatic reasons. The objectives of the present study were to describe the prevalence of oral symptoms among adults in Ouagadougou, capital city of Burkina Faso and the use of oral health services and self-medication in response to these symptoms and to measure the associations between predisposing, enabling and needs factors and decisions to seek oral health care.