To determine if patient aspirin exposure and timing affect bleeding risk after renal allograft biopsy.
Review of 6,700 renal allograft biopsies (in 2,362 unique patients) was performed. Median ...patient age was 53.0 years interquartile range 43.0, 62.0; 56.2% of patients were male. Of biopsies, 4,706 (70.2%) were performed in patients with no aspirin exposure within 10 days of biopsy; 664 (9.9%), were performed within 8-10 days of aspirin exposure; 855 (12.8%), within 4-7 days; and 475 (7.1%), within 0-3 days. Follow-up to 3 months after the procedure was completed in all patients. Biopsies were categorized as protocol or indication; 19.7% were indication biopsies. Bleeding complications were graded based on SIR criteria. Logistic regression models examined the association between aspirin use and bleeding events.
Rate 95% confidence interval of major bleeding complications was 0.24% 0.14, 0.39, and rate of any bleeding complication was 0.66% 0.46, 0.90. Bleeding events were significantly associated with patients undergoing indication biopsies compared with protocol biopsies (odds ratio OR 2.27, P = .012). Patient factors associated with major bleeding complications in multivariate models included estimated glomerular filtration rate (OR 0.61, P = .016) and platelet count (OR 0.64, P = .033). Aspirin use was not significantly associated with increased risk of bleeding complication except for use of 325 mg of aspirin within 3 days of biopsy (any complication OR 3.87 1.12, 13.4, P = .032; major complication OR 6.30 1.27, 31.3, P = .024).
Renal allograft biopsy bleeding complications are very rare, particularly for protocol biopsies. Use of 325 mg of aspirin within 3 days of renal allograft biopsy was associated with increased bleeding complications.
In this study, we show the use of three-dimensional printing models for preoperative planning of transcatheter valve replacement in a patient with an extreme porcelain aorta. A 70-year-old man with ...severe aortic stenosis and a porcelain aorta was referred to our center for transcatheter aortic valve replacement. Unfortunately, the patient died after the procedure because of a potential ischemic event. Therefore, we decided to fabricate three-dimensional models to evaluate the potential effects of these constructs for previous surgical planning and simulation of the transcatheter valve replacement.
Progress in the definition of the requirements for edge localized mode (ELM) control and the application of ELM control methods both for high fusion performance DT operation and non-active ...low-current operation in ITER is described. Evaluation of the power fluxes for low plasma current H-modes in ITER shows that uncontrolled ELMs will not lead to damage to the tungsten (W) divertor target, unlike for high-current H-modes in which divertor damage by uncontrolled ELMs is expected. Despite the lack of divertor damage at lower currents, ELM control is found to be required in ITER under these conditions to prevent an excessive contamination of the plasma by W, which could eventually lead to an increased disruptivity. Modelling with the non-linear MHD code JOREK of the physics processes determining the flow of energy from the confined plasma onto the plasma-facing components during ELMs at the ITER scale shows that the relative contribution of conductive and convective losses is intrinsically linked to the magnitude of the ELM energy loss. Modelling of the triggering of ELMs by pellet injection for DIII-D and ITER has identified the minimum pellet size required to trigger ELMs and, from this, the required fuel throughput for the application of this technique to ITER is evaluated and shown to be compatible with the installed fuelling and tritium re-processing capabilities in ITER. The evaluation of the capabilities of the ELM control coil system in ITER for ELM suppression is carried out (in the vacuum approximation) and found to have a factor of ∼2 margin in terms of coil current to achieve its design criterion, although such a margin could be substantially reduced when plasma shielding effects are taken into account. The consequences for the spatial distribution of the power fluxes at the divertor of ELM control by three-dimensional (3D) fields are evaluated and found to lead to substantial toroidal asymmetries in zones of the divertor target away from the separatrix. Therefore, specifications for the rotation of the 3D perturbation applied for ELM control in order to avoid excessive localized erosion of the ITER divertor target are derived. It is shown that a rotation frequency in excess of 1 Hz for the whole toroidally asymmetric divertor power flux pattern is required (corresponding to n Hz frequency in the variation of currents in the coils, where n is the toroidal symmetry of the perturbation applied) in order to avoid unacceptable thermal cycling of the divertor target for the highest power fluxes and worst toroidal power flux asymmetries expected. The possible use of the in-vessel vertical stability coils for ELM control as a back-up to the main ELM control systems in ITER is described and the feasibility of its application to control ELMs in low plasma current H-modes, foreseen for initial ITER operation, is evaluated and found to be viable for plasma currents up to 5-10 MA depending on modelling assumptions.
To describe the feasibility, safety, and effectiveness of a technique using vertebral augmentation balloons to promote delivery of cement into periacetabular tumors after cryoablation for fracture ...prevention.
A retrospective review was performed of seven consecutive patients (six men and one woman; mean age, 64 y ± 8) with unilateral periacetabular tumors (mean size, 4.2 cm ± 1.4) treated with cryoablation and balloon-assisted osteoplasty for fracture prevention. Cortical defects were seen in six (86%) tumors, and additional pathologic fractures occurred in five (71%) tumors before treatment. The cohort included six (86%) Harrington class I defects and one (14%) class II defect. Procedures were performed with computed tomography fluoroscopic guidance and general anesthesia. Vertebral augmentation balloons (mean, 2; range, 1-4) were inflated within the ablation cavity immediately before or during cement injection.
All procedures were technically successful. Median percentage tumor fill was 63% (range, 17%-96%). Minor cement leakage occurred in two (29%) patients with no symptomatic or intraarticular extravasation. A new nondisplaced fracture occurred in one patient and was conservatively managed. No major complications occurred. Local tumor progression occurred in one (20%) of five patients with imaging follow-up.
Balloon-assisted osteoplasty after cryoablation of periacetabular tumors appears feasible, safe, and effective for fracture prevention. This technique directs cement instillation into ablation defects with a high degree of filling and minimal leakage.
To evaluate success and complication rates of percutaneous ultrasound-guided thrombin injection of nongroin pseudoaneurysms (PSAs).
Retrospective review of a prospectively maintained institutional ...database yielded 39 cases of arterial PSAs occurring at nongroin sites that were treated with percutaneous ultrasound-guided thrombin injection between 2000 and 2016 (average patient age 69.2 y ± 14.0). Of PSAs, 74.4% (29/39) arose in the upper extremities, and 92.3% (36/39) were iatrogenic. The brachial artery was the most commonly affected vessel (51.3% 20/39), and arterial access was the most common cause (56.4% 22/39). Average overall PSA size was 2.4 cm (range, 0.5-7.2 cm); average amount of thrombin injected was 320 IU (range, 50-2,000 IU). Technical success was defined as absence of flow within the PSA immediately after thrombin injection. Treatment success was defined as sustained thrombosis on follow-up imaging obtained at 1-3 days after treatment.
Technical and treatment success rates of thrombin injections were 100% (39/39) and 84.8% (28/33), respectively. Longer term follow-up imaging (average 71 d; range, 12-201 d) was available for 7 of the treatment successes with 100% (7/7) showing sustained thrombosis. Comparing treatment successes and failures, there was no significant difference in average PSA size (2.3 cm vs 2.0 cm, P = .51) or average amount of thrombin injected (360 IU vs 180 IU, P = .14). There were no complications.
Ultrasound-guided thrombin injection is a safe, efficacious treatment option for PSAs arising in nongroin locations.
Abstract
Background
Surgical site infections (SSIs) represent ~ 20% of all hospital-acquired infections in surgical patients and are associated with prolonged hospital stay, admission to intensive ...care, and mortality. We conducted a systematic review with economic and environmental models to assess whether triclosan-coated sutures (Plus Sutures) provide benefits over non-coated sutures in the reduction of SSI risk.
Methods
Searches were conducted in fifteen databases. A total of 1,991 records were retrieved. Following deduplication and screening by two independent reviewers, 31 randomized controlled trials in adults and children were included in the review.
Similarity of the studies was assessed by narrative review and confirmed by quantitative assessment. A fixed effects meta-analysis of SSI incidence model including all groups of patients estimated a risk ratio of 0.71 (95% confidence interval: 0.64 to 0.79) indicating those in the Plus Sutures group had a 29% reduction in the risk of developing an SSI compared with those in the control group (
p
< 0.001). Safety outcomes were analysed qualitatively.
Results
The economic model estimated the use of Plus Sutures to result in average cost savings of £13.63 per patient. Plus Sutures remained cost-saving in all subgroup analyses with cost-savings ranging between £11 (clean wounds) and £140 (non-clean wounds).
The environmental impact of SSI is substantial, and the model suggests that the introduction of Plus Sutures could result in potential environmental benefits.
Conclusions
The evidence suggests that Plus Sutures are associated with a reduced incidence of SSI across all surgery types alongside cost savings when compared with standard sutures.
Abstract There still is no consensus on the treatment of choice in revision knee arthroplasty associated with severe femoral and/or tibial bone loss. A total of 44 patients underwent revision knee ...arthroplasty procedures using porous tantalum cones (TM cones) to reconstruct tibial and/or femoral bone defects. At latest follow up after 37 months (32–48), 38 patients remained in the study. Tibial and femoral bone loss was categorized according to the AORI-Classification. The average preoperative KSS improved from 34 (range, 6–90) to 63 points (range, 7–90 points). The VAS improved from 7.5 to 4.8. Two patients required a re-revision due to aseptic loosening. There was no correlation between the different types of knee prosthesis implanted. Our study shows favourable clinical and radiological outcomes using TM cones in managing significant bone loss in revision total knee surgery.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Summary Background Stage IIIB non-small-cell lung cancer (NSCLC) is usually thought to be unresectable, and is managed with chemotherapy with or without radiotherapy. However, selected patients might ...benefit from surgical resection after neoadjuvant chemotherapy and radiotherapy. The aim of this multicentre, phase II trial was to assess the efficacy and toxicity of a neoadjuvant chemotherapy and radiotherapy followed by surgery in patients with technically operable stage IIIB NSCLC. Methods Between September, 2001, and May, 2006, patients with pathologically proven and technically resectable stage IIIB NSCLC were sequentially treated with three cycles of neoadjuvant chemotherapy (cisplatin with docetaxel), immediately followed by accelerated concomitant boost radiotherapy (44 Gy in 22 fractions) and definitive surgery. The primary endpoint was event-free survival at 12 months. Efficacy analyses were done by intention to treat. This trial is registered with ClinicalTrials.gov , number NCT00030810. Findings 46 patients were enrolled, with a median age of 60 years (range 28–70). 13 (28%) patients had N3 disease, 36 (78%) had T4 disease. All patients received chemotherapy; 35 (76%) patients received radiotherapy. The main toxicities during chemotherapy were neutropenia (25 patients 54% at grade 3 or 4) and febrile neutropenia (nine 20%); the main toxicity after radiotherapy was oesophagitis (ten patients 29%; nine grade 2, one grade 3). 35 patients (76%) underwent surgery, with pneumonectomy in 17 patients. A complete (R0) resection was achieved in 27 patients. Peri-operative complications occurred in 14 patients, including two deaths (30-day mortality 5·7%). Seven patients required a second surgical intervention. Pathological mediastinal downstaging was seen in 11 of the 28 patients who had lymph-node involvement at enrolment, a complete pathological response was seen in six patients. Event-free survival at 12 months was 54% (95% CI 39–67). After a median follow-up of 58 months, the median overall survival was 29 months (95% CI 16·1–NA), with survival at 1, 3, and 5 years of 67% (95% CI 52–79), 47% (32–61), and 40% (24–55). Interpretation A treatment strategy of neoadjuvant chemotherapy and radiotherapy followed by surgery is feasible in selected patients. Toxicity is considerable, but manageable. Survival compares favourably with historical results of combined treatment for less advanced stage IIIA disease. Funding Swiss Group for Clinical Cancer Research (SAKK) and an unrestricted educational grant by Sanofi-Aventis (Switzerland).
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Cerebrovascular events (CVEs) are common among children supported with the Berlin EXCOR (Berlin Heart GmbH, Berlin, Germany) ventricular assist device (VAD). Given the high incidence of ...CVEs associated with this device, we sought to describe our institutional experience in incrementally reducing CVEs in children supported with the Berlin EXCOR VAD. Methods We collected pertinent data on 39 consecutive patients who underwent Berlin EXCOR VAD implantation at a single center. Frequency of CVEs was described in risk per implantation, per day, and in reference to the time of therapeutic anticoagulation. Risk factors were analyzed for association with CVEs. Results Of the initial 39 Berlin EXCOR VAD implantations, 16 CVEs occurred in 12 patients. The incidence of CVEs decreased with institutional experience per patient ( R2 = 0.6909, p = 0.007) and per patient-day ( R2 = 0.8051, p = 0.002). CVEs occurred more frequently before therapeutic anticoagulation targets were achieved (4.1%/day) compared with after therapeutic anticoagulation targets were achieved (0.9%/day; p = 0.044). Conclusions Incidence of CVEs decreased with institutional experience. The risk of CVE is highest in the immediate postoperative period before therapeutic anticoagulation is achieved. Further studies are warranted in pediatric patients supported with the Berlin EXCOR VAD to confirm our findings in a larger cohort.
PDF
