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The effect of epsilon-aminocaproic acid on HemoSTATUS and kaolin-activated clotting time measurements

New point-of-care assays have been used to identify patients with heparin resistance (i.e. heparin dose response test; Medtronic Blood Management, Parker, CO) and who have platelet dysfunction (i.e. HemoSTATUS; Medtronic Blood Management). We examined the effect of epsilon-aminocaproic acid on results from these two point-of-care tests in patients undergoing cardiac surgery. Twenty patients scheduled for elective cardiac surgical procedures were enrolled in this prospective study. HemoSTATUS clot ratio (% maximal) values in Channels (Ch) 3-6 (Ch 3: 26 +/- 25, Ch 4: 66 +/- 23, Ch 5: 84 +/- 20, Ch 6: 106 +/- 18) obtained after the IV administration of epsilon-aminocaproic acid were similar to values obtained before the administration of this agent (Ch 3: 26 +/- 20, Ch 4: 69 +/- 23, Ch 5: 86 +/- 19, Ch 6: 109 +/- 14). Slope values (86 +/- 23 s x U(-1) x mL(-1)) and projected heparin concentrations (4 +/- 1 U/mL) obtained before the administration of epsilon-aminocaproic acid were similar to slope values (88 +/- 21 s x U(-1) x mL(-1)) and projected heparin concentrations (4 +/- 1 U/mL) values obtained after administration of this agent. Our data indicate that HemoSTATUS clot ratio values and heparin dose response values are not significantly affected after IV dosing of epsilon-aminocaproic acid. Implications: Values from two activated coagulation time-based test systems used to identify significant heparin resistance or platelet dysfunction after cardiopulmonary bypass were not significantly affected by epsilon-aminocaproic acid administered IV.     

Evaluation of pulmonary blood flow in bilateral bidirectional Glenn shunts: value of 4‐D flow cardiac magnetic resonance in the evaluation of pulmonary artery confluence stenosis

Bilateral bidirectional Glenn shunts are associated with the risk of developing pulmonary artery bifurcation stenosis, resulting in variable pulmonary blood flow to either lung. This could negatively impact the subsequent stages of the single ventricle palliation pathway. This report highlights the value of 4D flow sequence from the cardiac magnetic resonance imaging in demonstrating the pulmonary blood flow characteristics following a bilateral bidirectional Glenn procedure. Mapping the blood flow pattern and its quantification to each lung provide objective insights into the possible predisposing factors for the development of pulmonary bifurcation stenosis.     

Real Time Three-Dimensional Echocardiography for the Evaluation of Cardiomyopathy

Cardiomyopathy refers to a set of diseases that are characterized by myocardial dysfunction. Classically, two-dimensional echocardiography has been used in the diagnosis of these disorders and to help guide their management. Three-dimensional transthoracic echocardiography is now increasingly being used in the diagnosis, management, and prognostication of intrinsic cardiomyopathies. In this article, we summarize the available data on the use of three-dimensional transthoracic echocardiography in various forms of intrinsic cardiomyopathy as well as some of its advantages over traditional two-dimensional transthoracic echocardiography. (Echocardiography 2012;29:76-87)     

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis

Background

The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics.

Methods

Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using χ², Fisher exact, and Student t tests.

Results

The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain).We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 ± 5.7 vs 8.8 ± 6.7 days, P = .08).

Conclusions

When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.     

Primary laparoscopic repair of high imperforate anus in neonatal males

Purpose

The standard approach to males with high imperforate anus has been a staged procedure starting with a descending colostomy, then posterior sagittal anorectoplasty with colostomy closure after 3 months. Recently, a minimally invasive approach to the repair of high imperforate anus has been described in infants after colostomy. We describe 6 newborn males with high imperforate anus successfully repaired laparoscopically as a primary, single-stage procedure.

Methods

A retrospective chart review was performed on all patients with imperforate anus from October 2003 to October 2006.

Results

We evaluated 9 newborn males with high imperforate anus. Of these patients, 6 underwent primary laparoscopic repair on day 1 to day 2 of life. Of these 6 patients, 3 were found to have bladder neck fistulas, whereas the other 3 had prostatic urethra fistulas. All patients passed stool within the first 72 hours postoperatively. One patient has required a procedure for a mild rectal prolapse. Follow-up ranges from 2 to 30 months in the single-stage group.

Conclusion

Our early results using primary laparoscopic repair appear encouraging. Laparoscopy allows excellent visualization and assessment of the fistula and repair of high imperforate anus without need for colostomy. Long-term follow-up will be needed to assess outcomes and continence rates.     

Compound palmar ganglion with carpal tunnel syndrome

Compound palmer ganglion is an uncommon condition characterized by a swelling in the distal part of volar aspect of wrist and communicating with another swelling over palm across the flexor retinaculum. It commonly results from tuberculous tenosynovitis. It may lead to carpal tunnel syndrome and need surgical excision with division of flexor retinaculum.     

Hepatitis B and C virus infections transmitted through organ transplantation investigated by CDC,United States, 2014‐2017

We evaluated clinical outcomes among organ recipients with donor‐derived hepatitis B virus (HBV) or hepatitis C virus (HCV) infections investigated by CDC from 2014 to 2017 in the United States. We characterized new HBV infections in organ recipients if donors tested negative for total anti‐HBc, HBsAg and HBV DNA, and new recipient HCV infections if donors tested negative for anti‐HCV and HCV RNA. Donor risk behaviors were abstracted from next‐of‐kin interviews and medical records. During 2014‐2017, seven new recipient HBV infections associated with seven donors were identified; six (86%) recipients survived. At last follow‐up, all survivors had functioning grafts and five (83%) had started antiviral therapy. Twenty new recipient HCV infections associated with nine donors were identified; 19 (95%) recipients survived. At last follow‐up, 18 (95%) survivors had functioning grafts and 14 (74%) had started antiviral treatment. Combining donor next‐of kin interviews and medical records, 11/16 (69%) donors had evidence of injection drug use and all met Public Health Service increased risk donor (IRD) criteria. IRD designation led to early diagnosis of recipient infection, and prompt implementation of therapy, likely reducing the risk of graft failure, liver disease, and death.