Contraindications Research Articles

The effects of previous abdominal surgery and the utilisation of modified access techniques on the operative difficulty and outcomes of laparoscopic cholecystectomy and bile duct exploration

BackgroundEarly reports suggested that previous abdominal surgery was a relative contraindication to laparoscopic cholecystectomy (LC) on account of difficulty and potential access complications. This study analyses different types/systems of previous surgery and locations of scars and how they affect access difficulties. As modified access techniques to minimise risk of complications are under-reported the study details and evaluates them.MethodProspectively collected data from consecutive LC and common bile duct explorations (LCBDE) performed by a single surgeon over 30 years was analysed. Previous abdominal surgery was documented and peri-operative outcomes were compared with patients who had no previous surgery using Chi-squared analysis.ResultsOf 5916 LC and LCBDE, 1846 patients (31.2%) had previous abdominal surgery. The median age was 60 years. Those with previous surgery required more frequent duodenal (RR 1.07; p = 0.023), hepatic flexure (RR 1.11; p = 0.043) and distal adhesiolysis (RR 3.57; p < 0.001) and had more access related bowel injuries (0.4% vs. 0.0%; p < 0.001). Previous upper gastrointestinal and biliary surgery had the highest rates of adhesiolysis (76.3%), difficult cystic pedicles (58.8%), fundus-first approach (7.2%), difficulty grades (64.9% Grades 3–5) and utilisation of abdominal drains (71.1%). Previous open surgery resulted in longer operative time compared to previous laparoscopic procedures (65vs.55 min; p < 0.001), increased difficulty of pedicle dissection (42.4% vs. 36.0%; p < 0.05) and required more duodenal, hepatic flexure and distant adhesiolysis (p < 0.05) and fundus-first dissection (4% vs 2%; p < 0.05). Epigastric and supraumbilical access and access through umbilical and other hernias were used in 163 patients (8.8%) with no bowel complications.ConclusionThe risks of access and adhesiolysis in patients with previous abdominal scars undergoing biliary surgery are dependent on the nature of previous surgery. Previous open, upper gastrointestinal and biliary surgery carried the most significant risks. Modified access techniques can be adopted to safely mitigate these risks.Graphical abstract

Effectiveness of ballistic exercises for increasing upper body explosive power in physical education lessons for university students

Background and Study Aim. Explosive power is an important element of fitness levels, with fast muscle contractions being required in most physical activities. Study implements and verifies the effects of ballistic exercises with medicine balls of various weights on upper body explosive strength for non-sporting university students. Material and Methods. The study involved 184 male and 143 female undergraduate students, all 21 years old. These students had no medical contraindications to participating in the activities required by the physical education program. The development of upper body explosive strength was conducted using ballistic exercises, specifically various types of medicine ball throws, over one academic year. The evaluation comprised six tests: Overhand Ball Throw, Overhead Medicine Ball Throw-forward, Overhead Medicine Ball Throw-backward, Medicine Ball Chest Throw, Shot Put - Track and Field, and 30 s Plyometric Push-Ups. These tests were scheduled at three different times during the academic year: October, December, and May. Results. The results of the Analysis of Variance (ANOVA) with repeated measurements indicate F values associated with statistically significant thresholds (p &lt; 0.05). In contrast, partial eta squared (η²p) values demonstrate a stronger effect of ballistic exercise application for the male group. Significant improvements in results were observed for both genders from one test to another. The differences were notably larger between the test conducted before the winter holiday (December) and the test at the end of the second semester (May) compared to those between the test at the beginning of the academic year (October) and the one before the winter holiday (December). This pattern indicates a clear improvement in muscle strength in the second semester (January-May). The only test where high percentages of men, and especially women, encountered problems was the 30-second Plyometric Push-Ups. In the final tests, 10% of males and 40% of females scored zero. Conclusions. Ballistic exercises based on various medicine ball throws prove to be an attractive and effective solution to improve upper body muscle strength for non-sporting university students. The application of these exercises can significantly enhance physical education programs by providing clear benefits in terms of strength development. This is particularly evident in environments aimed at general student populations rather than athletes. Furthermore, while the exercises are broadly beneficial, they may require modifications to address the challenges some students face.

Preconception counseling impact in pregnancy outcomes in patients with spondyloarthritis

Introduction: Spondyloarthritis (SpA) is a group of chronic inflammatory diseases, often affecting women in reproductive age, which can have a significant impact on the reproductive health of women. Preconception counselling and medication adjustments have shown to reduce flares and improve pregnancy outcomes in women with rheumatoid arthritis. However, in women with SpA, data of the impact of preconception counselling on pregnancy outcomes is scarce. The aim of this study is to evaluate its impact. Methods: In this retrospective multicentric study, data was collected from medical records of women who gave birth from 2020 to 2022. The study included 45 pregnancies, which were divided into two categories - whether they received preconception consultation or not. Data was collected on patient characteristics, disease duration, medications used, and preconception counselling. Maternal and foetal outcomes were studied. Results: In this study involving 45 patients, radiographic axial spondyloarthritis was the most prevalent type (16 cases), with psoriatic arthritis showing the highest preconception consultation rate (80.0%), with an average of 33.90 years. Lower rates of contraindicated medication were used during pregnancy (0.0%) in counselled patients versus those without counselling (20.0%). Sulfasalazine usage was higher in non-counselled patients (77.8%), while certolizumab pegol use was higher in counselled patients (33.3%). Pregnancy outcomes showed no significant difference in successful pregnancies, but counselled patients experienced significantly fewer postpartum flares (6.4% vs 36.6%). Gestational age at delivery and newborn weight did not significantly differ between groups. Foetal malformation occurred in 2.6% of the population, with no significant difference based on counselling status. Conclusion: Preconception counselling in women with SpA can increase the likelihood of medication adjustments before pregnancy and decrease the occurrence of flares postpartum. These findings suggest that preconception counselling should be implemented in the management of pregnant women with SpA to improve pregnancy outcomes. Further studies are needed to confirm the effectiveness of preconception counselling and to determine the optimal approach.

Profile of patients referred for lung transplant and their transplant-free survival.

Lung transplant (LTx) is a potential treatment option for all patients with chronic, end-stage respiratory disease, who are refractory to optimal medical therapy or where no medical therapy exists. In India, LTx is still in its evolving stages and published literature is sparse. The current study was carried out to study the selection criteria for lung transplant and to evaluate the clinical and socio-economic profile of patients referred for the same at a tertiary health care facility. The study was a descriptive, prospective, observational study. All adults referred for lung transplant were evaluated for clinical and laboratory profiles. All enrolled patients were assessed for presence of referral criteria, listing criteria, contraindications, and willingness for lung transplant. These patients were followed up for 2 years for transplant-free survival, and the Cox proportional hazards model was used to determine independent predictors of all-cause mortality. A total of 103 were included in study. The most common diagnosis was interstitial lung disease (57.2%), followed by bronchiectasis (17.5%) and COPD (13.6%). Most patients were referred for LTx at an advanced stage as 90% met listing criteria. Fifty-four (52.4%) patients had an absolute or relative contraindication to transplant; however, the majority of those contraindications were modifiable. Patients with a lower socio-economic status were less likely to be willing for LTx. The median survival was 757 days. A 6-minute walk distance (6MWD) lesser than 250 m was found to be an independent predictor of mortality. Making patients aware about lung transplant early in their treatment may give them sufficient time to come to terms with their disease and understand the risk and benefits associated. Efforts should be focused on screening and early treatment of reversible contraindications for the eligible patients. Patients with 6MWD < 250 m are at increased risk of mortality.

Diagnostic value of the gingival cytogram in school-age children suffering from chronic gastritis and duodenitis

In recent years, there has been an increase in the incidence of morbidity associated with digestive organ pathology in the pediatric population. The oral cavity is the digestive tract opening, sharing a common ectodermal origin with it. The changes in the cytogram of the oral mucous membranes can signal about exacerbation of pathological processes in the gastrointestinal tract. The aim of this work: to identify the features of gingival cellular composition in school-age patients with chronic gastritis and duodenitis in order to improve diagnostic methods at the disease stages. Examinations of the gingival cytogram in children aged 12-17 years with chronic gastritis and duodenitis (27 individuals with the disease in acute stage, 30 – in remission) were carried out. The control group included 28 children who did not have any somatic pathology by the results of the examination. For cytological examination, imprint smears from the gingival vestibular surface of the upper and lower jaws were made. The smears were fixed and stained by the May-Grunwald Pappenheim method, and then examined using a microscope with an im­mersion system. The percentage of epithelial cells and connective tissue cells was calculated per 100 cells. The number of pathologically altered epithelial cells was determined: with vacuolated cytoplasm, with nucleus deformation. In children with chronic gastritis and duodenitis disorders in the gingival cellular composition with a predominance of dystrophic components were found, that was manifested by a decrease in the proportion of epithelial cells at terminal stages of differentiation, an increase in the proportion of cells with cytopathological phenomena, polymorphonuclear leukocytes and lymphocytes. Changes in the cytogram were especially expressed in the phase of disease exacerbation. Knowing the phases of the wound process, based on the timing and sequence of the cellular ensembles seen in the cytogram, it is possible to control the disease periods, and timely apply measures to prevent exacerbations. This diag­nostic method is especially indicated for children who have relative and absolute contraindications for fibroesogastroduodenoscopy.

Proceedings of PRINCETON IV: PDE5 inhibitors and cardiac health symposium.

Prior consensus meetings have addressed the relationship between phosphodiesterase type 5 (PDE5) inhibition and cardiac health. Given significant accumulation of new data in the past decade, a fourth consensus conference on this topic was convened in Pasadena, California, on March 10 and 11, 2023. Our meeting aimed to update existing knowledge, assess current guidelines, and make recommendations for future research and practice in this area. An expert panel reviewed existing research and clinical practice guidelines. Key findings and clinical recommendations are the following: First, erectile dysfunction (ED) is a risk marker and enhancer for cardiovascular (CV) disease. For men with ED and intermediate levels of CV risk, coronary artery calcium (CAC) computed tomography should be considered in addition to previous management algorithms. Second, sexual activity is generally safe for men with ED, although stress testing should still be considered for men with reduced exercise tolerance or ischemia. Third, the safety of PDE5 inhibitor use with concomitant medications was reviewed in depth, particularly concomitant use with nitrates or alpha-blockers. With rare exceptions, PDE5 inhibitors can be safely used in men being treated for hypertension, lower urinary tract symptoms and other common male disorders. Fourth, for men unresponsive to oral therapy or with absolute contraindications for PDE5 inhibitor administration, multiple treatment options can be selected. These were reviewed in depth with clinical recommendations. Fifth, evidence from retrospective studies points strongly toward cardioprotective effects of chronic PDE5-inhibitor use in men. Decreased rates of adverse cardiac outcomes in men taking PDE-5 inhibitors has been consistently reported from multiple studies. Sixth, recommendations were made regarding over-the-counter access and potential risks of dietary supplement adulteration. Seventh, although limited data exist in women, PDE5 inhibitors are generally safe and are being tested for use in multiple new indications. Studies support the overall cardiovascular safety of the PDE5 inhibitors. New indications and applications were reviewed in depth.

Influence of Schneiderian Membrane Perforation on Implant Survival Rate: Systematic Review and Meta-Analysis.

Background: Maxillary sinus lift is a well-documented and accepted technique in the rehabilitation of the posterior maxilla. Schneiderian membrane perforation is the most common complication and may occur in between 7% and 56% of cases. Different materials and techniques have been described to achieve reparation of the perforation. The aim of this study was to establish whether the perforation of the Schneiderian membrane and its repair during maxillary sinus lift surgery results in a lower implant survival rate compared to those cases where the membrane has not been perforated. Materials and methods: A systematic review and meta-analysis of studies assessing the survival rate of implants placed in regenerated sinus using the lateral window approach, where the perforation of the Schneiderian membrane occur, was carried out. Statistical analysis was performed with Open Meta-Analyst, calculating the odds ratio of implants placed in perforated sinuses and non-perforated sinuses. Results: Ten articles were included in the qualitative analysis and seven articles in the quantitative analysis or meta-analysis. A total of 1224 maxillary sinus augmentation surgeries were performed without perforation of the Schneiderian membrane and 2725 implants were placed; 62 implants failed during the follow-up period with an overall survival rate of 97.7%. In 480 perforated sinuses, 1044 implants were placed, of which 30 failed; the overall survival rate was 97.1%. There were no significant differences between the implant survival rate of the implants in the two groups (OR = 0.78; CI = 0.49-2.23; p = 0.28 and I2 heterogeneity: 0%, p = 0.44). Conclusions: Schneiderian membrane perforation, as long as it is repaired, does not appear to negatively influence implant survival rate. Membrane perforation should not be considered a reason to abort the procedure or an absolute contraindication to implant placement.

Characterizing the Association Between Traumatic Brain Injury and Discontinuation of Medications for Opioid Use Disorder in a Commercially Insured Adult Population.

Extending prior research that has found that people with traumatic brain injury (TBI) experience worse substance use treatment outcomes, we examined whether history of TBI was associated with discontinuation of medication to treat opioid use disorder (MOUD), an indicator of receiving evidence-based treatment. We used MarketScan claims data to capture inpatient, outpatient, and retail pharmacy utilization from large employers in all 50 states from 2016 to 2019. We identified adults aged 18 to 64 initiating non-methadone MOUD (ie, buprenorphine, injectable naltrexone, and oral naltrexone) in 2016-2019. The exposure was whether an individual had a TBI diagnosis in the 2years before initiating MOUD. During this period, there were 709 individuals with TBI who were then matched with 709 individuals without TBI. We created a retrospective cohort of matched individuals with and without TBI and used quasi-experimental methods to identify the association between TBI status and MOUD use. We estimated propensity scores by TBI status and created a 1:1 matched cohort of people with and without TBI who initiated MOUD. We used a Cox proportional hazards model to identify the association between TBI and MOUD discontinuation. The outcome was discontinuation of MOUD (ie, a gap of 14days or more of MOUD). Among those initiating MOUD, the majority were under 26years of age, male, and living in an urban setting. Nearly 60% of individuals discontinued medication by 6months. Adults with TBI had an elevated risk of MOUD discontinuation (hazard ratio [HR] 1.13; 95% confidence interval [CI], 1.01-1.27) compared to those without TBI. Additionally, initiating oral naltrexone was associated with a higher risk of discontinuation (HR 1.63; 95% CI, 1.40-1.90). We found evidence of reduced MOUD retention among people with TBI. Differences in MOUD retention may reflect health care inequities, as there are no medical contraindications to using MOUD for people with TBI or other disabilities.

ANALYSIS OF TRANEXAMIC ACID USAGE IN ADULT SPINAL DEFORMITY PATIENTS WITH RELATIVE CONTRAINDICATIONS IN PAKISTAN

Patients who require complex spinal surgery require a huge amount of blood transfusion perioperatively. The anemia, the formation of hematoma, and increased coagulation properties, which are consequences of massive blood loss itself can negatively affect the postoperative clinical results.Objectives: The main objective of the study is to find the tranexamic acid usage in adult spinal deformity patients with relative contraindications in Pakistan. Methodology of the study: This prospective observational study was conducted at Pakistan institute of medical sciences from 2016-2020. Data were collected from 185 patients of spine deformity.Data were collected through a combination of medical record reviews and direct patient interviews. Demographic details, including age, gender, weight, and height, were recorded for each of the 185 patients. Comprehensive medical histories were obtained to identify comorbid conditions and relative contraindications for tranexamic acid (TXA) use, such as a history of thromboembolic events, renal impairment, and concurrent anticoagulant therapy. Results: Data were collected from 185 patients according to criteria of the study. Mean age of the patients were 58.4 ± 12.3 years. Out of 185, there were 112 (60.5%) females and 73 (39.5%) male patients. Mean BMI was 28.1 ± 5.4 kg/m2. 49.7% were also suffering from hypertension, 24.3% from DM and 20% from osteoporosis.The regression coefficient (β) for total blood loss was -250 mL, with a 95% confidence interval (CI) of [-300, -200], and a p-value of &lt; 0.001. Similarly, the regression coefficient for the number of blood transfusions was -1.2 units, with a 95% confidence interval of [-1.5, -0.9], and a p-value of &lt; 0.001.Conclusion: Tranexamic acid effectively reduces blood loss and transfusion requirements in adult spinal deformity surgeries, even among patients with relative contraindications. The associated complication rates are manageable with careful patient selection and monitoring.

Psychosocial Evaluation of Living Kidney Donors: A Survey of Current Practices in the United States.

Best practices in psychosocial evaluation and care of living donor candidates and donors are not well established. We surveyed 195 living kidney donor (LKD) transplant centers in United States from October 2021 to April 2022 querying (1) composition of psychosocial teams, (2) evaluation processes including clinical tools and domains assessed, (3) selection criteria, and (4) psychosocial follow-up post-donation. We received 161 responses from 104 programs, representing 53% of active LKD programs and 67% of LKD transplant volume in 2019. Most respondents (63%) were social workers/independent living donor advocates. Over 90% of respondents indicated donor candidates with known mental health or substance use disorders were initially evaluated by the psychosocial team. Validated psychometric or transplant-specific tools were rarely utilized but domains assessed were consistent. Active suicidality, self-harm, and psychosis were considered absolute contraindications in >90% of programs. Active depression was absolute contraindication in 50% of programs; active anxiety disorder was excluded 27%. Conditions not contraindicated to donation include those in remission: anxiety (56%), depression (53%), and posttraumatic stress disorder (41%). There was acceptance of donor candidates using alcohol, tobacco, or cannabis recreationally, but not if pattern met criteria for active use disorder. Seventy-one percent of programs conducted post-donation psychosocial assessment and use local resources to support donors. There was variation in acceptance of donor candidates with mental health or substance use disorders. Although most programs conducted psychosocial screening post-donation, support is not standardized and unclear if adequate. Future studies are needed for consensus building among transplant centers to form guidelines for donor evaluation, acceptance, and support.

Door-to-Balloon Time in ST-Elevation Myocardial Infarction (STEMI) Patients Undergoing Primary Angioplasty in Myocardial Infarction (PAMI): An Observational Study From a Tertiary Care Centre.

Background ST-elevation myocardial infarction (STEMI) requires swift intervention, with primary percutaneous coronary intervention (PCI) being essential to limit myocardial damage. The key factor affecting PCI effectiveness is the door-to-balloon (DTB) time. This observational study evaluated DTB times in STEMI patients at a tertiary care center who underwent primary angioplasty, examining adherence to benchmarks and identifying factors contributing to delays. Methodology This prospective observational study was conducted from March 2017 to August 2018 at Fortis Hospital Mulund, Mumbai, India. It included 171 STEMI patients aged 18 and older who underwent primary angioplasty. Patients with non-ST elevation myocardial infarction (NSTEMI), those who received thrombolysis, or had medical contraindications to primary angioplasty were excluded. Data on key time intervals were collected via direct observation and then analyzed using SPSS for Windows, Version 15 (Released 2006; SPSS Inc., Chicago, United States). Qualitative data were summarized using frequency and percentages, whereas quantitative data were presented as mean (±SD). T-test was applied to compare the mean duration between the two groups, i.e., DTB time ≤90 minutes and DTB time >90 minutes, and a p-value <0.05 was considered statistically significant. Results The participants had a mean age of 56.5 (±13.1) years and were predominantly male (78.4%). The mean DTB time was 70.21 (±29.16) minutes, with 79.5% achieving ≤90 minutes. Patient-related delays (48.6%) were mainly due to consent issues (31.4%), which was the most predominant cause. Hospital-related delays (51.4%) included catheterization laboratory occupancy (14.3%) and diagnostic delays (14.3%). Patients with DTB times >90 minutes had significantly longer durations in all procedural steps except door-to-ECG time. Conclusion This study underscores the complex challenges in achieving timely DTB times for STEMI patients undergoing primary angioplasty. Overcoming these barriers through targeted interventions is essential for optimizing management and enhancing outcomes. Insights into delay factors inform evidence-based strategies to improve the timeliness and effectiveness of STEMI care delivery.

Future of left atrial appendage interventions.

Percutaneous left atrial appendage occlusion (LAAO), currently recognized as a procedure with relatively low risk, is increasingly being adopted in clinical practice. However, due to the preventive nature of the procedure and the necessity to compare it with newer and safer oral anticoagulants, further optimization is required to address remaining challenges. These latter include acquiring comprehensive data on safety and efficacy, establishing standardized pre-procedural planning, and simplifying procedural process. Consequently, we have provided an overview that encompasses future opportunities for enhancing procedural safety and efficacy, thereby establishing LAAO as the mainstream strategy for stroke and systemic embolism prevention in patients with atrial fibrillation and absolute contraindications to anticoagulant drugs.

Topical and Intralesional Immunotherapy for the Management of Basal Cell Carcinoma.

Basal Cell Carcinoma (BCC) is the most common type of cancer among the white population. Individuals with fair skin have an average lifetime risk of around 30% for developing BCC, and there is a noticeable upward trend in its incidence rate. The principal treatment objectives for BCC involve achieving the total excision of the tumor while maximizing the preservation of function and cosmesis. Surgery is considered the treatment of choice for BCC for two main reasons: it allows for the highest cure rates and facilitates histological control of resection margins. However, in the subgroup of patients with low-risk recurrence or medical contraindications for surgery, new non-surgical treatment alternatives can provide an excellent oncological and cosmetic outcome. An evident and justified instance of these local therapies occurred during the COVID-19 pandemic, a period when surgical interventions carried out in hospital settings were not a viable option.

Prevention is better than healing. Clinical and economic implications of oral antiviral agents in COVID-19: a prospective study

COVID-19 represents a threat for frailty patients. This study compares molnupiravir and nirmatrelvir for fragile COVID- 19 patients' efficacy, safety, and cost. An observational, prospective study allowed us to evaluate molnupiravir’s efficacy and safety in real life, compare it to a subgroup of patients treated with nirmatrelvir-ritonavir, and analyze its cost-effectiveness. From January to December 2022, 435 patients (225 males, 220 females; median age 72 years), were enrolled; 24 patients were unvaccinated, and 280 patients had ≥2 risk factors. Molnupiravir performed better clinically and economically. Compared to literature data, in these patients, hospitalization was 2.5% vs. 6.8% (P&lt;0.005), overall adverse effects 14,3% vs. 30.4% (P&lt;0.0001), severe adverse effects 2.6 vs. 6.9% (P&lt;0.001), thus involving potential total savings of about € 92.954 per patient (8% of standard of care cost). Early molnupiravir treatment helped fragile patients who partially responded to the vaccine, or with absolute contraindications to vaccination, to overcome COVID-19 without the need for hospitalization. In elderly patients with multiple pathologies and multiple drugs, molnupiravir prevents disease progression clinically and economically.

The acceptability of hospital-at-home for persons living with cancer and their caregivers.

1548 Background: Hospital at Home (HaH) is part of a comprehensive patient-centered model that delivers multidisciplinary acute medical care in the home. While HaH has mainly been tested in general medical patients, uncertainties persist regarding the feasibility and acceptability of this model within oncology populations. This study assessed patient and caregiver characteristics associated with acceptability of a hypothetical HaH program in persons hospitalized with cancer and described patient medical needs. Methods: A cross-sectional survey assessing acceptability of a hypothetical HaH program, home characteristics, and demographics was completed by 250 patients and 33 caregivers. Eligible patients were English-speaking adults (18+ years) admitted to the medicine service at a cancer hospital. Acceptability was measured on a 5-point Likert scale and defined as responses of “strongly agree” or “agree” to the statement, “I would consent to the use of my home for my hospital care” if such a program were available. Surveys were conducted in person or via telephone during the index hospitalization. Unpaid adult caregivers were surveyed in person and acceptability of the hypothetical HaH program was similarly assessed. Characteristics of the hospitalization were assessed via the electronic health record. Continuous variables were compared between acceptability groups using Wilcoxon rank sum test; categorical variables were compared using Fisher’s exact test and Pearson’s chi-squared test. Results: Median patient age was 63, 134 (54%) were female, 38 (16%) identified as Black and 21 (8.8%) as Hispanic, and 171 (72%) completed some college education or more. 208 patients (83%) rated participation in HaH as acceptable, as did 28 (85%) caregivers. Patients living with metastatic disease were more likely to accept HaH (p&lt;0.05). Acceptability differed by race (p&lt;.05) and was lowest among Black patients (74%) and those who preferred not to provide their race (70%). Of those who rated HaH acceptable, 137 (66%) had advanced imaging or a surgical procedure after the first day of admission and 21 (10%) had an absolute contraindication to being hospitalized at home such as a home member using illicit drugs at home (15, 7%). Conclusions: Over 80% of persons hospitalized with cancer and their caregivers would agree to HaH. Those with advanced disease were more likely to agree to home hospitalization compared to curative-intent patients, but Black patients were less likely to agree to be hospitalized at home compared to white patients. Many patients had hospitalization characteristics (e.g., imaging) that may be challenging to coordinate from home, but few patients had safety-related contraindications to HaH. These findings will inform future efforts to evaluate and target HaH programs in oncology to patients most likely to agree to and benefit from them, and address barriers to uptake in certain racially minoritized populations.

Frontal fibrosing alopecia—A new absolute contraindication for deep chemical peels

Frontal fibrosing alopecia (FFA) is characterized by a receding hairline in the frontotemporal region due to the gradual loss of hair follicles and then follicular stem cells and follicular fibrosis. Follicular stem cells are crucial in skin healing after chemical peeling and other resurfacing procedures. Although there is a possible association of FFA with a history of facial and scalp surgical procedures, there is no information on the safety of cosmetic procedures in patients with FFA. We report five patients with FFA who experienced unusual and complicated outcomes after undergoing a deep chemical peel (phenol and croton oil). As the prevalence of FFA continues to increase globally, it is essential to raise awareness about the potential incompatibility of this dermatologic disorder with specific cosmetic procedures, such as deeper peels and other resurfacing modalities.

Living donor liver transplantation for patients with portal vein thrombosis: high-volume single center experience.

End-stage liver disease is commonly associated with portal vein thrombosis (PVT). Lastly, PVT is no longer an absolute contraindication for liver transplantation, and many centers adopt portal vein thrombectomy. PVT imposes special technical difficulties during living donor liver transplantation (LDLT). In this research, the experience with PVT cases during LDLT in a high-volume center is introduced. Between January 2018 and July 2023, 312 patients underwent LDLT. After 88 cases were excluded, 224 cases were included, and their incidence of pre-transplant PVT was 16.5% (37/224). Demographic and clinical features, perioperative variables, and post-transplant outcomes of patients with PVT (PVT group, n=37) were compared to patients who had no PVT (non-PVT group, n=187). According to Yerdel classification, 16, 16, 2, and 3 patients had PVT grade I, II, III, and IV, respectively. Complete venous thrombectomy was accomplished in 34 patients, while for three patients, thrombectomy was not feasible, and graft inflow was established by interposition vascular graft. For portal flow modulation, splenectomy and splenic artery ligation were performed in 7 and 4 patients, respectively, while two patients underwent post-transplant splenic artery embolization. The PVT group had longer operation time (p<0.001), longer warm ischemia time (p=0.031), longer anhepatic phase (p<0.001), and intraoperatively required more than 3 packed RBCs units (p=0.029) and ≥1 platelet unit transfusion (p=0.021) than the non-PVT group. No statistically significant difference was found between groups in terms of re-exploration (p=0.954), post-transplant PVT (p=0.375), biliary (p=0.253) and arterial complications (p=0.593), ICU stay (p=0.633), hospital stay (p=896), and 30-day mortality (p=1.000). Survival analysis showed no statistically significant difference regarding 1-year survival (p=0.176) between both groups. This study showed that patients with different stages of PVT can successfully undergo LDLT in experienced centers and that they do not differ from patients without PVT in terms of post-transplant complications.

Case report: three ways to mitigate the risk of embolization during left atrial appendage closure in a patient with a massive and proximal left atrial appendage thrombus

Abstract Background Left atrial appendage (LAA) thrombus is a contraindication for LAA closure (LAAC). However, in selected cases, oral anticoagulants are strictly contraindicated because of a history of life-threatening bleeding, and LAAC remains the only possible therapy to avoid systemic and especially cerebral embolization. Case summary We report a case of LAAC despite a massive proximal thrombus in a patient who had an absolute contraindication to anticoagulant therapy, with thorough pre-planning using CT scan, device modelling and thrombus trapping techniques to reduce the risk of systemic embolic events and perform LAAC safely. Discussion Although LAAC remains at high risk in this setting, the use of cautious techniques and tools, from pre-procedure planning to systemic embolization prevention systems associated to a precise transoesopheageal echocardiography guiding throughout the procedure, allows it to be performed as safely as possible when no other option is available.

Percutaneous pulmonary thrombectomy with aspiration catheters in patients with high-risk pulmonary embolism and absolute contraindication to systemic thrombolysis

BackgroundHigh-risk Pulmonary Embolism (PE) mortality remains very high. Systemic thrombolysis is effective but carries significant complications and contraindications related to the hemorrhagic risk. Percutaneous thrombectomy using aspiration catheters may be an alternative in patients with a high bleeding risk. ObjectiveThis study aimed to evaluate the results of catheter-directed thrombectomy using aspiration dedicated catheters in patients with high-risk PE and absolute contraindication to systemic thrombolysis, with specific focus on procedural success, safety, and in-hospital outcomes. MethodsA prospective study enrolled all consecutive patients diagnosed with high-risk pulmonary embolism and absolute contraindication to systemic thrombolysis, who underwent percutaneous pulmonary thrombectomy using dedicated aspiration catheters. The study documented the effectiveness and complications of the procedure, as well as patient outcomes at discharge and during the follow-up period. ResultsThirteen patients underwent percutaneous pulmonary thrombectomy using aspiration dedicated catheters. The procedure was successful for all patients, resulting in hemodynamic and respiratory improvement within the first 24 h. No deaths attributable to cardiovascular or respiratory causes occurred during admission or follow-up. Furthermore, no serious adverse events or complications were reported during the procedure or hospitalization. ConclusionsPercutaneous pulmonary thrombectomy with dedicated aspiration catheters in patients with high-risk pulmonary embolism and contraindications to systemic thrombolysis was associated with excellent clinical results and low rate of complications.

Xevinapant with radiation and concurrent carboplatin and paclitaxel in patients ineligible for cisplatin with locoregionally advanced squamous cell carcinoma of the head and neck (EXtRaCT study).

TPS6126 Background: Locoregionally advanced (LA) head and neck cancer (HNC) patients undergoing chemoradiotherapy (CRT) who are ineligible for cisplatin have comparatively poor outcomes, with only ~40% alive at 5 years. There is an urgent unmet need to improve survival in these vulnerable patients with no standard therapeutic approach. Xevinapant, an oral inhibitor of XIAP and cIAP1/2, sensitizes cancer cells to apoptosis. Randomized phase II results in patients eligible for cisplatin combining xevinapant with CRT showed improved locoregional control, manageable toxicity, and promising survival outcomes. (Sun et al. Lancet Oncol. 2020) The current trial aims to extend these benefits to patients ineligible for cisplatin using xevinapant with carboplatin-paclitaxel-based CRT, hypothesizing safety and tolerability in this high-risk group. Methods: This phase I dose escalation/expansion study investigates xevinapant combined with carboplatin and paclitaxel to treat LA HNC in patients ineligible for cisplatin. Key eligibility includes previously untreated LA HNC and specific cisplatin ineligibility criteria, including &gt;=70yo with moderate to severe comorbidity or vulnerability (Geriatric-8 score ≤ 14 and/or CARG score ≥ 30%) or &lt;70yo with severe comorbidity and/or vulnerability, or &gt;=18yo with an absolute contraindication to cisplatin. The treatment regimen comprises escalating doses of oral xevinapant (50-200 mg daily) on days 1-14 of a 21-day cycle for 3 cycles concurrent with CRT and 3 cycles adjuvant, weekly carboplatin AUC 1.5 IV, and paclitaxel 30 mg/m2 IV for 7 doses, and radiotherapy to 70 Gy in standard 2Gy fractions over 7 weeks with primary endpoint of tolerability and recommended phase 2 dose. A Bayesian-modified toxicity probability interval design will identify the maximum tolerated dose (MTD), targeting a 25% dose-limiting toxicity rate, with a sample size of 24 patients in dose-finding. 18 additional patients will be enrolled in the dose-expansion cohort at the MTD, totaling 42 patients. Secondary objectives include safety, response, progression-free, overall survival, and locoregional and distant control. Exploratory aims: in-clinic geriatric evaluations (Katz ADL, Lawton iADL, MMSE), QoL surveys, symptom tracking via smartphone, and wearable-derived steps and sarcopenia assessment. Recruitment began 02/2024. Clinical trial information: NCT06110195 .