To compare paediatric oncologic vascular access ports located on the anterior thoracic wall to ports on the lower lateral thoracic wall, in terms of perceived port-related hindrance and scar-quality.
...A cross-sectional survey study including paediatric oncology patients (≥8-<19 yrs), caregivers (in patients <8 yrs), survivors (>22 yrs with only anterior ports) and nurses of the Princess Máxima Center, the Netherlands, was performed. The survey consisted of questions regarding satisfaction, hindrance during daily life, and port position preference. For survivors, scar-quality was assessed using the validated Patient and Observer Scar Assessment Scale (POSAS 2.0); a high score (i.e., a displeasing scar) was defined as a score higher than the third quartile of the median for that question.
In total, 147 participants were included; 83 patients/caregivers, 31 survivors, and 33 nurses. Overall, 81 % was satisfied with the position of their port. Satisfaction, hindrance and complications did not differ between anterior and lower lateral ports. For the anterior position, minimal pressure on the port during daily life was a mentioned reason to prefer this position. For the lower lateral position, less visibility of the scar and easiest access were mentioned. Of all survivors with an anterior port scar, one in five had a displeasing scar and all scars observed were widened. Female patients preferred a lower lateral port, and scar-quality was better for left-sided port scars.
The port position should be chosen together with patients/caregivers based on the (dis-)advantages of each position, as identified by this study.
II.
•Satisfaction, hindrance and complications did not differ between anterior and lower lateral ports.•The most ideal port position should therefore be chosen together with patients/caregivers based on the (dis-)advantages of each position.
Sentinel node procedures (SNP) are performed with the use of tracer-agents, mainly radio-colloid and/or blue dye. Fluorescent agents have emerged as a new tracer-agent to identify the SLN ...intra-operatively with near-infrared imaging. Our aim is to compare the detection rate of fluorescent agents to current “golden standards” (blue dye and/or radio-colloid) for the SNP by means of a systematic review and meta-analysis without any restrictions based on tumor type.
A systematic search in PubMed, Embase and The Cochrane Library was performed. Articles that compared the detection rates of fluorescent agents with radio-colloid and/or blue dye were included. Meta-analyses were performed for breast, gynecological and dermatological cancer using a random effects model.
In total 6195 articles were screened which resulted in a final inclusion of 55 articles. All studies used indocyanine green (ICG) as fluorescent agent. Meta-analyses comparing ICG with blue dye showed a significant and clinically relevant difference in detection rate in favor of ICG, for both breast, dermatological and gynecological cancer. Meta-analyses comparing ICG with radio-colloid did not show any significant differences, with the exception of ICG versus radio-colloid + blue dye for the bilateral SLN detection in gynecological cancer.
Near-infrared fluorescence imaging using ICG provides a higher detection rate compared to blue dye for the SNP in a range of different tumor types. SLN detection rates of ICG are comparable to radio-colloid. Due to their complementary characteristics in terms of spatial resolution and transdermal sensitivity, we suggest to use a combination of both ICG and a radio-colloid.
•This meta-analysis concerns breast, gynecological and dermatological SNP studies•Indocyanine green (ICG) provides a higher SLN detection rate compared to blue dye•SLN detection rates of ICG are comparable to radio-colloids•ICG and radio-colloids have complementary characteristics•We suggest to use a combination of both ICG and a radio-colloid for the SNP
Purpose
Resection of pediatric osteosarcoma in the extremities with soft tissue involvement presents surgical challenges due to difficult visualization and palpation of the tumor. Therefore, an ...adequate image-guided surgery (IGS) system is required for more accurate tumor resection. The use of a 3D model in combination with intraoperative tracked ultrasound (iUS) may enhance surgical decision making. This study evaluates the clinical feasibility of iUS as a surgical tool using a porcine cadaver model.
Methods
First, a 3D model of the porcine lower limb was created based on preoperative scans. Second, the bone surface of the tibia was automatically detected with an iUS by a sweep on the skin. The bone surface of the preoperative 3D model was then matched with the bone surface detected by the iUS. Ten artificial targets were used to calculate the target registration error (TRE). Intraoperative performance of iUS IGS was evaluated by six pediatric surgeons and two pediatric oncologic orthopedists. Finally, user experience was assessed with a post-procedural questionnaire.
Results
Eight registration procedures were performed with a mean TRE of 6.78 ± 1.33 mm. The surgeons agreed about the willingness for clinical implementation in their current clinical practice. They mentioned the additional clinical value of iUS in combination with the 3D model for the localization of the soft tissue components of the tumor. The concept of the proposed IGS system is considered feasible by the clinical panel, but the large TRE and degree of automation need to be addressed in further work.
Conclusion
The participating pediatric surgeons and orthopedists were convinced of the clinical value of the interaction between the iUS and the 3D model. Further research is required to improve the surgical accuracy and degree of automation of iUS-based registration systems for the surgical management of pediatric osteosarcoma.
The aim of the present study was to assess whether a single measurement of the digital brachial index (DBI; systolic finger pressure/systemic pressure ratio), reflecting the arm's circulation, was ...associated with access patency in patients with severe chronic kidney disease scheduled for arteriovenous fistula (AVF) creation.
A bilateral DBI was obtained using digital plethysmography just before construction of the patient's first AVF from January 2009 to December 2017 at one center. A DBI of 80% to 99% was considered normal, and a DBI of <80% (low) or DBI of ≥100% (high) were considered abnormal. DBI values ipsilateral to the AVF were used for analysis. The primary and secondary access patency rates were calculated using reported standards and compared using standard statistical techniques.
Data sets of 163 patients were obtained (69 women; age, 71 ± 12 years). The median follow-up was 40 weeks (range, 0-104 weeks; follow-up index, 99% ± 1%). Patients with abnormal preoperative DBI values had lower 2-year primary patency rates (low DBI, 25% ± 11%; high DBI, 28% ± 6%; normal DBI, 49% ± 8%; P = .018). After correction for age, sex, hypertension, diabetes mellitus, cardiovascular disease, smoking status, and a history of ipsilateral central venous catheter use, an adjusted model demonstrated that abnormal DBI values conferred an increased risk of primary patency failure (low DBI <80%: hazard ratio HR, 2.25; 95% confidence interval CI, 1.13-4.48; high DBI ≥100%: HR, 1.74; 95% CI, 1.06-2.85; P < .030 for both). Patients with a low preoperative DBI had also had diminished secondary patency (HR, 2.86; 95% CI, 1.08-7.59; P = .035). In contrast, the diameters of the outflow veins did not determine access patency.
Patients with abnormal DBI values before AVF construction for hemodialysis had lower 2-year access patency rates compared with patients with a normal DBI. Plethysmographic finger measurements might have a role in the preoperative counseling of patients with severe chronic kidney disease requiring an AVF.
Abstract
Background
The aim of this study was to determine associations between characteristics of arteriovenous access (AVA) flow volume (Qa; mL/min) and 4-year freedom from cardiovascular mortality ...(CVM) in haemodialysis (HD) patients.
Methods
HD patients who received a primary AVA between January 2010 and December 2017 in one centre were analysed. Initial Qa was defined as the first Qa value obtained in a well-functioning AVA by a two-needle dilution technique. Actual Qa was defined as access flow at a random point in time. Changes in actual Qa were expressed per 3-month period. CVM was assessed according to the European Renal Association–European Dialysis and Transplant Association classification. The optimal cut-off point for initial Qa was identified by a receiver operating characteristics curve. A joint modelling statistical technique determined longitudinal associations between Qa characteristics and 4-year CVM.
Results
A total of 5208 Qa measurements (165 patients; 103 male, age 70 ± 12 years, autologous AVA n = 146, graft n = 19) were analysed. During follow-up (December 2010–January 2018, median 36 months), 79 patients (48%) died. An initial Qa <900 mL/min was associated with an increased 4-y CVM risk {hazard ratio HR 4.05 95% confidence interval (CI) 1.94–8.43, P < 0.001}. After 4 years, freedom from CVM was 34% lower in patients with a Qa <900 mL/min (53 ± 7%) versus a Qa ≥900 mL/min (87 ± 4%; P < 0.001). An association between increases in actual Qa per 3-month period and mortality was found HR 4.48/100 mL/min (95% CI 1.44–13.97), P = 0.010, indicating that patients demonstrating increasing Qa were more likely to die. In contrast, actual Qa per se was not related to survival.
Conclusions
Studying novel AVA Qa characteristics may contribute to understanding excess CVM in HD patients.
Volume flow (Qa) > 1.5–2 l /minQa in arteriovenous accesses may be associated with high flow related systemic or locoregional complications. A variety of surgical techniques are advocated for Qa ...reduction. Aim of this scoping review is to provide an overview of available evidence regarding the efficacy of this broad spectrum of interventions for Qa reduction in patients with a high flow haemodialysis access. PubMed and Embase were searched according to PRISMA-guidelines. Studies on invasive management of HFA were selected. Inclusion required an English description of surgical techniques in human HFAs including pre- and postoperative access flow-values. Sixty-six studies on 940 patients (mean age 56 years (3–90 years), male 62%, diabetes mellitus 26%, brachial artery-based arteriovenous access 65%) fulfilled inclusion criteria. Performed techniques were banding (58%), revision using distal inflow (12%), plication/anastomoplasty (10%), graft interposition (5%), proximal radial artery ligation (3%), aneurysm repair (4%), or miscellaneous other techniques (8%). Definition of HFA, work-up, indication for surgery and intraoperative monitoring were diverse. All techniques reduced Qa on the short term (mean drop 0.9–1.7 l/min). Secondary access patency rates varied between 70% and 93% (mean follow-up 15 (0–189) months). Definitions of success and recurrence varied widely precluding a comparison of efficacy of techniques. Patient specific factors legitimizing invasive treatment for HFA are discussed. Recommendations on reporting standards when dealing with HFA surgery are provided. In conclusion, the present report on the current management of high flow access does not allow for drawing any definite conclusions due to a lack of standardization in definition, indications for surgical intervention and techniques. Randomized trials comparing different Qa reducing techniques in symptomatic patients are warranted, as are trials comparing a wait-and-see approach versus Qa reduction in asymptomatic patients. As an overview of the variety of techniques was lacking, this scoping review might serve as a map for future researchers.
Objective/Background A previous budget impact analysis regarding a supervised exercise therapy (SET) first treatment strategy (stepped care model SCM) for Dutch patients with intermittent ...claudication (IC) showed a low referral rate in 2009, despite solid evidence of the effectiveness of SET programs. Recently, several campaigns have stimulated stakeholders in the field to adopt a SET first strategy in patients with IC. The aim of the present study was to reassess SCM adherence after a 2 year period. Methods IC related invoices of patients in 2011 were obtained from a large Dutch health insurance company (3.5 million persons). Patients were divided into two groups based on their initial treatment. A SET group had started SET between 12 months before (initiated by general practitioner) and 3 months after (initiated by vascular surgeon) presentation at a vascular surgery outpatient clinic. An intervention (INT) group was treated by revascularisation within 3 months of outpatient presentation. Costs of IC treatment in this 2011 cohort were compared with the earlier 2009 cohort. Results IC related invoices of 4135 patients were available. In 2011, the initial treatment was SET in 56% (2009: 34%; +22% p < .001) and INT in 44% (2009: 66%; −22% p < .001) of the IC population. Additional revascularisation was performed in 19% of patients in the SET group (2009: 6%; +13% p < .001) and also in 19% of patients in the INT group (2009: 35%; −16% p < .001). Later on, 29% of patients in the INT group were referred for SET (2009: 10%; +19% p < .001). Average costs of IC treatment per patient in 2011 were 6% lower than in 2009 (€6885 vs. €7300; p = .020). Conclusion A 22% increase in adherence to SET as a first treatment strategy in Dutch patients with IC was attained between 2009 and 2011. This shift suggests successful SCM implementation resulting in lower costs for the national healthcare system.
In-transit metastases (ITM) are defined as metastatic lymph nodes or deposits occurring between the primary tumor and proximal draining lymph node basin. In extremity rhabdomyosarcoma (RMS), they ...have rarely been reported. This study evaluates the frequency, staging and survival of patients with ITM in distal extremity RMS.
Patients with extremity RMS distal to the elbow or knee, enrolled in the EpSSG RMS 2005 trial between 2005 and 2016 were eligible for this study.
One hundred and nine distal extremity RMS patients, with a median age of 6.2 years (range 0–21 years) were included. Thirty seven of 109 (34%) had lymph node metastases at diagnosis, 19 of them (51%) had ITM, especially in lower extremity RMS. 18F-FDG-PET/CT detected involved lymph nodes in 47% of patients. In patients not undergoing 18F-FDG-PET/CT lymph node involvement was detected in 22%. The 5-yr EFS of patients with ITM vs proximal lymph nodes vs combined proximal and ITM was 88.9% vs 21.4% vs 20%, respectively (p = 0.01) and 5-yr OS was 100% vs 25.2% vs 15%, respectively (p = 0.003).
Our study showed that in-transit metastases constituted more than 50% of all lymph node metastases in distal extremity RMS. 18F-FDG-PET/CT improved nodal staging by detecting more regional and in-transit metastases. Popliteal and epitrochlear nodes should be considered as true (distal) regional nodes, instead of in-transit metastases. Biopsy of these nodes is recommended especially in distal extremity RMS of the lower limb. Patients with proximal (axillary or inguinal) lymph node involvement have a worse prognosis.
Revision using distal inflow (RUDI) is currently proposed in patients on hemodialysis having a high flow access (HFA; >2 L/min) or hemodialysis access-induced distal ischemia (HAIDI). However, a ...recurrence of high flow or hand ischemia is not unusual in the years after RUDI. The aim of the present study was to describe changes in flow characteristics and arterial diameters in the dialysis arm after RUDI for HFA.
Volume flow, diameter, peak systolic velocity and end diastolic velocity of the brachial artery (BA) were studied 2 and 12 months after RUDI using duplex imaging. In a portion of patients, these characteristics were also assessed at proximal and distal portions of radial and ulnar arteries (proximal forearm radial artery, distal radial artery, ulnar artery, and distal ulnar artery), and in the greater saphenous venous interponate. HFA patients were grouped according to presence of concomitant hand ischemia (HFA-HAIDI) or absence (HFA).
Fifteen patients (54 ± 16 year old; 10 males; HFA-HAIDI, n = 6; HFA, n = 9) with a BA HFA (flow volume, 2740 ± 322 mL/min) undergoing RUDI were studied between March 2011 and October 2016 in two Dutch hospitals. After 2 months, flow volume had decreased (1180 ± 189 mL/min), but again increased at 12 months (1520 ± 217 mL/min; P < .001). BA diameters did not change (7.4 ± 0.5 mm), but proximal forearm radial diameters doubled (overall 2.6 ± 0.2 mm to 5.4 ±1.0 mm; P < .001), albeit less prominent in HFA-HAIDI (+80%) than in HFA (+130%; P = .019). During follow-up, the distal ulnar artery peak systolic velocity in HFA-HAIDI (83 ± 10 cm/s) was higher compared with the HFA group (54 ± 5 cm/s; P < .01). Dilatation was not present in the greater saphenous venous interponate.
RUDI for HFA reduction does not reverse BA dilatation, suggesting irreversible structural arterial wall damage possibly contributing to recurrent high flow. Radial artery remodeling is attenuated in HFA patients previously reporting concurrent hand ischemia diminishing the likelihood of high flow recurrence in this subgroup.
PDF
