General and Acute Care Surgical Procedures in Patients with Left Ventricular Assist Devices

Background

Left ventricular assist devices (LVADs) have become common as a bridge to heart transplant as well as destination therapy. Acute care surgical (ACS) problems in this population are prevalent but remain ill-defined. Therefore, we reviewed our experience with ACS interventions in LVAD patients.

Methods

A total of 173 patients who received HeartMate^® XVE or HeartMate^® II (HMII) LVADs between December 2001 and March 2010 were studied. Patient demographics, presentation of ACS problem, operative intervention, co-morbidities, transplantation, complications, and survival were analyzed.

Results

A total of 47 (27 %) patients underwent 67 ACS procedures at a median of 38 days after device implant (interquartile range 15–110), with a peri-operative mortality rate of 5 % (N = 3). Demographics, device type, and acuity were comparable between the ACS and non-ACS groups. A total of 21 ACS procedures were performed emergently, eight were urgent, and 38 were elective. Of 29 urgent and emergent procedures, 28 were for abdominal pathology. In eight patients, the cause of the ACS problem was related to LVADs or anticoagulation. Cumulative survival estimates revealed no survival differences if patients underwent ACS procedures (p = 0.17). Among HMII patients, transplantation rates were unaffected by an ACS intervention (p = 0.2).

Conclusions

ACS problems occur frequently in LVAD patients and are not associated with adverse outcomes in HMII patients. The acute care surgeon is an integral member of a comprehensive approach to effective LVAD management.     

Biomechanical advantage of C1 pedicle screws over C1 lateral mass screws: a cadaveric study

Purpose

The established technique for posterior C1 screw placement is via the lateral mass. Use of C1 monocortical pedicle screws is an emerging technique which utilizes the bone of the posterior arch while avoiding the paravertebral venous plexus and the C2 nerve root. This study compared the relative biomechanical fixation strengths of C1 pedicle screws with C1 lateral mass screws.

Methods

Nine human C1 vertebrae were instrumented with one lateral mass screw and one pedicle screw. The specimens were subjected to sinusoidal, cyclic (0.5 Hz) fatigue loading. Peak compressive and tensile forces started from ±25 N and constantly increased by 0.05 N every cycle. Testing was stopped at 5 mm displacement. Cycles to failure, displacement, and initial and end stiffness were measured. Finally, CT scans were taken and the removal torque measured.

Results

The pedicle screw technique consistently and significantly outperformed the lateral mass technique in cycles to failure (1,083 ± 166 vs. 689 ± 240 cycles), initial stiffness (24.6 ± 3.9 vs. 19.9 ± 3.2 N/mm), end stiffness (16.6 ± 2.7 vs. 11.6 ± 3.6 N/mm) and removal torque (0.70 ± 0.78 vs. 0.13 ± 0.09 N m). Only 33 % of pedicle screws were loose after testing compared to 100 % of lateral mass screws.

Conclusions

C1 pedicle screws were able to withstand higher toggle forces than lateral mass screws while maintaining a higher stiffness throughout and after testing. From a biomechanical point of view, the clinical use of pedicle screws in C1 is a promising alternative to lateral mass screws.     

High prevalence of urogenital infection/inflammation in patients with azoospermia does not impede surgical sperm retrieval

Considering infection/inflammation to be an important risk factor in male infertility, the aim of this study was to make a comprehensive evaluation of the prevalence of urogenital tract infection/inflammation and its potential impact on sperm retrieval in azoospermic patients. In this prospective study, 71 patients with azoospermia were subjected to an extensive andrological workup including comprehensive microbiological diagnostics (2‐glass test, semen, testicular swab and testicular tissue analysis) and testicular biopsy/testicular sperm extraction (TESE). Medical history suggested urogenital tract infection/inflammation in 7% of patients, 11% harboured STIs, 14% showed significant bacteriospermia, 15% had seminal inflammation, 17% fulfilled the MAGI definition, and 27% had relevant pathogens. At the testicular level, 1 patient had a swab positive for bacteria, no viruses were detected, tissue specimens never indicated pathogens, whereas histopathology revealed focal immune cell infiltrates in 23% of samples. Testicular sperm retrieval rate was 100% in obstructive and 46% in nonobstructive azoospermia. None of the infection/inflammation‐related variables was associated with the success of sperm retrieval or inflammatory lesions in the testis. The high prevalence of urogenital infection/inflammation among azoospermic men underpins their role as significant aetiologic factors in male infertility. However, this observation does not refer to the chances of sperm retrieval at the time of surgery/TESE.     

Is there an impact of cervical plating on the development of adjacent segment degeneration following Smith-Robinson procedure? A magnetic resonance imaging study of 84 patients with a 24-year follow-up

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) without and with cervical plating (ACDF+CP) are accepted surgical techniques for the treatment of degenerative cervical disc disorders. The effect of CP on the development of adjacent segment degeneration (ASD) remains unclear.

Ambulante Palliativmedizin

Background

The right to adequate outpatient palliative care has existed for several years in Germany. In recent years outpatient palliative care has developed very positively. Nevertheless, in emergency situations paramedics and emergency physicians were often included in the care of palliative care of patients. The aim of our study was to investigate the cooperation between outpatient palliative care teams and the emergency medical services. Another aim was to identify structural realities and based on these to discuss the possibilities in the optimization of outpatient palliative medical emergency situations.

Methods

A standardized self-designed questionnaire was distributed to specialized outpatient palliative care teams (SPCS) in Germany. For this purpose, closed and open questions (mixed methods) were used. The evaluation was carried out according to the questionnaire categories in quantitative and qualitative forms. The questionnaire was subdivided into general information and specific questions.

Results

The survey response rate was 79% from a total of 81 SPCS in 2011. The following standards in palliative emergency care were recommended: (1) early integration of outpatient palliative care services and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, emergency drug boxes, do not attempt resuscitation orders and (4) emergency medical training (physicians and paramedics).

Conclusion

Outpatient palliative care in Germany has developed very positively during the last years; however, there are still deficits in terms of optimal patient care, one of which refers to the treatment of palliative care emergencies. In this context, optimization in the cooperation between outpatient palliative care services and emergency medical services should be discussed.