Thromboelastography-Based Transfusion Algorithm Reduces Blood Product Use after Elective CABG: A Prospective Randomized Study

Abstract   Objective: Bleeding and allogeneic transfusion remain constant problems in cardiac surgical procedures. In this study, we aimed to test the role of a routine thromboelastography (TEG)-based algorithm on bleeding and transfusions in patients undergoing elective coronary artery bypass grafting (CABG). Methods: Patients (n = 224) undergoing elective CABG with cardiopulmonary bypass were prospectively randomized into two groups according to transfusion strategy: in group 1 (clinician-directed transfusion, n = 110) need for blood transfusion was based on clinician's discretion and standard coagulation tests and in group 2 (TEG algorithm group, n = 114) kaolin-activated (k) TEG-based algorithm-guided perioperative transfusion management. Transfusion, blood loss, and outcome data were recorded.  Results: There were no differences in consumption of packed cell units, blood loss, re-exploration for bleeding, and early clinical outcome between the groups. Patients in the TEG group had significantly lower median units of fresh frozen plasma and platelets compared with the other group (p = 0.001). The median number of total allogeneic units transfused (packed cells and blood products) was significantly reduced in the TEG group compared with the other group (median 2, range 1–3 units vs. median 3, range 2–4 units, respectively, p = 0.001). The need for tranexamic acid was significantly diminished in the TEG group compared with the other group (10.3% vs. 19%, respectively, p = 0.007). Conclusion: Our results show that routine use of a kTEG-guided algorithm reduces the consumption of blood products in patients undergoing elective CABG. Adopting such an algorithm into routine management of these patients may help to improve clinical outcome and reduce the potential risks of transfusion-related complications and total costs after CABG.     

Mitral valve repair in a patient with Ter Haar Syndrome

Ter Haar Syndrome is one of the most deteriorating disorders defined in the medical era. Up to date only ten patients were reported. We present a living patient with Ter Haar Syndrome who has undergone successful mitral valve repair.     

The efficacy, safety and tolerability of pantoprazole-based one-week triple therapy in H. pylori eradication and duodenal ulcer healing

OBJECTIVE: Recently, proton pump inhibitor (PPI)-based triple therapy has been recommended as a first line treatment in the eradication of Helicobacter pylori. The aim of this open, multicentre trial was to investigate the efficacy, safety, tolerability and the ulcer healing rate of a triple regimen consisting of pantoprazole 40 mg, clarithromycin 500 mg and amoxicillin 1000 mg twice daily for 7 days, in the eradication of H. pylori in patients with duodenal ulcer in Turkey. RESEARCH DESIGN AND METHODS: H. pylori infection was assessed by histological examination and rapid urease test at baseline and 4 weeks after the completion of the therapy. Seventy-seven patients were enrolled, 5 were excluded due to various reasons and 72 completed the entire course of the trial. RESULTS: H. pylori eradication was confirmed in 49 of these patients; the eradication rate was 68% by per-protocol analysis and 63.6% by intention-to-treat analysis. The ulcers were completely healed in 61 patients (85%) at the second endoscopic examination. Drug compliance was excellent (97.3%) and there were no serious adverse events. CONCLUSION: Pantoprazole-based 1-week triple therapy was well tolerated and the ulcer healing rate was high (85%). Relatively low H. pylori eradication rates may be attributed to rising antibiotic resistance over recent years. A large scale, comparative study with other PPI-based regimens is warranted based on the results of this open study with the pantoprazole-based regimen.     

Single-piece foldable acrylic intraocular lens implantation in the sulcus in eyes with posterior capsule tear during phacoemulsification

PURPOSE: To evaluate early and late period results of the implantation of single-piece foldable acrylic intraocular lens (IOL) in the sulcus in eyes developing a posterior capsule tear (PCT) during phacoemulsification (PE). SETTING: S.S.K. Vakif Gureba Training Hospital Eye Clinic, Istanbul, Turkey. METHODS: This prospective and noncomparative study consisted of 89 eyes of 88 patients in which PCT developed, with or without vitreous loss, and that were followed up for at least 1 year. The IOL was implanted in the sulcus in all eyes with sufficient capsule support. Postoperative best corrected visual acuity (BCVA), anterior segment biomicroscopy, intraocular pressure (IOP), IOL centralization, and fundus were analyzed. RESULTS: Temporary corneal edema, the most frequently observed cause of reduced vision in the early period, appeared in 33 eyes; high IOP in 17 eyes; anterior chamber inflammatory reaction in 5 eyes; clinical cystoid macular edema in 7 eyes; and retinal detachment in 1 eye. The IOL was decentered in 4 eyes and dislocated in 1 eye. Repositioning was performed in 2 eyes. No IOL was removed. In the early period, BCVA was 5/10 and above in 41 eyes; the final BCVA was 4/10 and below in 16 eyes and of 5/10 and above in 73 eyes. CONCLUSIONS: The implantation of foldable acrylic IOL in the sulcus in eyes developing posterior capsule tear during phacoemulsification surgery maintains the advantages of a small incision. Postoperative visual results were good, complications were few, and IOLs were centered.     

Benign bone tumors in children

When children present for evaluation of bone tumor, great anxiety often occurs among the family. Usually the diagnosis of a benign bone tumor can be made easily with plain radiographs without biopsy. Most have a good outcome. However, occasionally, serious complications can develop. Moreover, the physician must be aware of the possibility of the malignant tumors. To avoid errors in the evaluation and treatment of this heterogeneous group of tumors, the clinician should have a good knowledge base of common bone neoplasms and correlate the clinical, radiographic, and pathologic findings. In this article, history, diagnosis, evaluation, treatment, and management of common types of benign tumors of bone commonly seen in children and adolescents are reviewed in the light of current literature.     

Skeletal traction and delayed percutaneous fixation of complicated supracondylar humerus fractures due to delayed or unsuccessful reductions and extensive swelling in children

The functional and radiological results of 13 supracondylar humerus fractures of 13 children were evaluated to determine the efficiency of delayed percutaneous fixation of the fractures after a period of skeletal overhead traction. All the fractures were complicated by delayed reduction, extensive swelling or unsuccessful reduction manipulations. As the unfavourable preexisting factors subsided under skeletal traction, anatomical reduction and fixation of fractures by percutaneous pinning were performed under general anesthesia. The average follow-up period was 21 months. Bauman and lateral capitellohumeral angles were measured and statistically analyzed. Functional and cosmetic results were evaluated by physical examination of the elbows. There were 11 excellent and two fair functional results while all cosmetic results were excellent or good. As a result, skeletal traction and delayed percutaneous pinning is accepted as an alternative method of treatment for complicated supracondylar humerus fractures in children.     

Replantation of a crush amputation of distal tibia followed by lengthening with Ilizarov circular external fixator: two-year follow-up

A 20-year-old male sustained a severe crush injury to his left leg, resulting in amputation of the foot at the level of the distal tibia. Despite 12-h warm ischemia, replantation was attempted after radical debridement, bone shortening, and proximal fasciotomies. The replanted part survived totally. Four months later, a 13-cm shortness of the extremity was managed by 10-cm lengthening with distraction osteogenesis, using Ilizarov's circular external fixator and by means of a special shoe. Two-year follow-up of the patient revealed acceptable functional and sensorial recovery. Success of replantation despite the excessive warm-ischemia time was attributed to the sparse muscle content of the distal tibia and foot. Fasciotomies performed on the proximal segment of the leg ensured the patency of anastomoses by maintaining adequate blood flow distally despite increasing edema after the crush injury. Debridement and bone shortening at the proximal stump eliminated the vein and nerve grafts to bridge the gap. In conclusion, considering the functional outcome of our case, replantation of distal parts of a lower extremity should be attempted first, even if the nature of the injury is unfavorable and the ischemia time is longer than the documented ischemia-tolerance.