Drop In Hemoglobin Level Research Articles

PS155 Effects of Ischemic Postconditioning on Sizes of Myocardial Infarction Induced by Ischemia/Reperfusion and Toll-R4 Expression in Rats

A significant proportion of patients with knee osteoarthritis have articular degeneration that is limited to the medial and patellofemoral compartments. The objective of this study was to compare clinical outcomes of unlinked bicompartmental knee arthroplasty (BCA) and total knee arthroplasty (TKA) at 5 years in this subset of patients.48 patients were randomised into two groups: unlinked, modular bicompartmental arthroplasty and total knee arthroplasty. Data on demographics and clinical outcomes were collected (Bartlett Knee Score, Oxford Knee Score, Knee Society Score). Data on intra-operative blood loss in both groups were also recorded.Out of the 48 patients, 26 underwent BCA and 22 had TKA. Both groups shared similar demographic profiles. At five years post surgery, there was significant improvement across all functional scores in both groups. However, there was no significant difference in outcome scores in the BCA group compared to the TKA group. The drop in serum haemoglobin levels postoperatively was 1.55 and 2.30 g/dl for the BCA and TKA groups respectively (p < .001). The total amount of blood loss was 397 and 647 ml respectively (p = .001).Unlinked, modular BCA results in similar clinical and functional scores as TKA for medial and patellofemoral arthritis in the mid-term. Intra-operative blood loss was significantly lower in the BCA group compared to the TKA group. BCA is a viable option for a select group of young and active patients with the advantage of reduced intra-operative blood loss and equivalent functional outcomes as TKA.

In utero treatment of severe fetal anemia resulting from fetomaternal red blood cell incompatibility: a comparison of simple transfusion and exchange transfusion

ObjectiveTo compare in utero exchange transfusions (IUET) and in utero simple transfusions (IUST) for the treatment of fetal anemia resulting from red blood cell fetomaternal incompatibility. Study designRetrospective comparative study from January 2006 through December 2011. The two techniques were compared for effectiveness, complications, and neonatal outcomes. Results36 patients had 87 IUETs and 85 patients 241 IUSTs. Gestational age at the first transfusion was similar in both groups (IUET: 27±3.8 weeks; IUST: 27±4.7 weeks; NS) as was the initial fetal hemoglobin level (IUET: 6.4±2.8g/dL; IUST: 6.0±2.5g/dL; NS). No significant differences were noted for postprocedure complications or efficacy. The daily drop in hemoglobin level was similar in both groups (IUET: 0.41±0.23g/dL/day; IUST: 0.44±0.17g/dL/day; NS) as were the time intervals between two procedures. Gestational age at birth was earlier in the IUET group (34.4±1.3 weeks vs 35.5±1.8 weeks; p<0.001), but the postnatal transfusions or exchange transfusions rates and the duration of intensive phototherapy did not differ. No significant differences were noted for the overall survival rates (IUET: 100%; IUST: 96.4%; p>0.99). ConclusionIUET does not appear to provide any benefits compared with IUST, neither to be associated with a higher complication rate. The choice of the technique depends on availability of packed blood cells with high hematocrit (70–80%).

Risk factors for fever and sepsis after percutaneous nephrolithotomy

ObjectivePercutaneous nephrolithotomy (PCNL) is commonly used in the management of large renal stones. Postoperative infections are one of the most common complications of this procedure. The present study is to determine and assess the factors that may increase the risk to develop fever and urinary sepsis after PCNL. MethodsA total of 60 patients (38 males and 22 females) with a mean age of 40.25 years enrolled in this study in Sulaimania Teaching Hospital. Patients had renal stone disease need operation with different socioeconomic status, body mass index and different type and size of stones were included in this study. Patients with preoperative positive urine culture and sensitivity were excluded. Preoperative investigations done for all patients. All Patients received prophylactic antibiotic gentamicin intravenously at the induction of anaesthesia. Renal pelvis urine sample were taken from all patients after puncturing the pelvicalyceal system and send for culture and sensitivity. Patients were monitored closely in the postoperative period for the development of fever and sepsis. ResultsMean duration of the operations was 77.08 min ranged 40–120 min. All patients had postoperative nephrostomy tube. Seventeen (28.33%) patients developed post PCNL fever and the statistically significant factors for post PCNL fever were diabetes mellitus (DM) (p = 0.001), stone burden (p = 0.001), number of the stones (p < 0.001), degree of hydronephrosis (p = 0.001), duration of the operation (p < 0.001), residual stones (p = 0.001) and number of tracts (p = 0.038). Three (5.00%) patients developed post PCNL sepsis, and the statistically significant risk factors for post PCNL sepsis were duration of the operation (p = 0.013) and intraoperative blood loss, postoperative drop in haemoglobin (HB) level (p = 0.046). ConclusionDM, staghorn stones, degree of hydronephrosis, duration of the operation and number of tracts are risk factors for post PCNL fever, while number of stones, intraoperative blood loss, duration of the operation and residual stones are risk factors for post PCNL sepsis.

The efficacy of topical tranexamic acid in total hip arthroplasty: a meta-analysis.

sBackgroundTopical tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after total knee arthroplasty. However, the effectiveness of topical TXA use in total hip arthroplasty (THA) still remains unclear. The purpose of this meta-analysis is to examine the safety and efficacy of topical use of TXA following THA.Hypothesis: Topical TXA reduces blood loss and transfusion rates without increasing risk of deep vein thrombosis in patients with THA.MethodsAn electronic literature search of PubMed, Embase, the Cochrane Library, Web of Science and Chinese Biomedical Database was performed, to identify studies published before February 2015. All randomized controlled trials and cohort studies evaluating the efficacy of topical TXA during THA were included. Two independent authors identified the eligible studies, assessed their methodological quality, and extracted data. The data were using fixed-effects or random-effects models with (standard) mean differences and risk ratios for continuous and dichotomous variables, respectively. Data were analysed using RevMan 5.3 software.ResultsFourteen studies encompassing 2594 patients met the inclusion criteria for our meta-analysis. Our meta-analysis indicated that when compared with the placebo group, topical use of TXA significantly reduced total blood loss (MD = −297.65 ml, 95 % CI −371.68 ml, 116.08 ml; P < 0.01), drainage loss (MD = −164.68 ml, 95 % CI −236.63 ml, −92.73 ml; P < 0.01), transfusion rate (RR = 0.26, 95 % CI 0.17, 0.40; P < 0.01) and with less of a drop in haemoglobin level (SMD = −0.66, 95 % CI −0.91, −0.41; P < 0.01) after primary THA. No significant difference in length of hospital stay (MD = −0.40, 95 % CI −0.91, 0.11; P = 0.14), deep vein thrombosis (RR = 1.19, 95 % CI 0.40, 3.57; P = 0.16) and pulmonary embolism (RR = 1.11, 95 % CI 0.11, 10.81; P = 0.21) among the study groups.ConclusionsTopical TXA could significantly reduce total blood loss, drainage loss, transfusion rates and decrease haemoglobin level following THA, without increasing risk of venous thromboembolisms.

Decision making on timing of surgery for hip fracture patients on clopidogrel.

Patients taking clopidogrel who sustain a fractured neck of femur pose a challenge to orthopaedic surgeons. The aim of this study was to determine whether delay to theatre for these patients affects drop in haemoglobin levels, need for blood transfusion, length of hospital stay and 30-day mortality. A retrospective review of all neck of femur patients admitted at two centres in the North East of England over 3 years revealed 85 patients. Patients were divided into two groups depending on whether they were taking clopidogrel alone (C) or with aspirin (CA). Haemoglobin drop was significantly different in the CA group that was operated on early (CA1) versus the group for which surgery was delayed by over 48 hours (CA2): 3.3g/dl and 1.9g/dl respectively (p=0.01). The mean inpatient stay in group C was 35.9 days while in group CA it was 19.9 days (p=0.002). The mean length of stay in group CA2 (26.7 days) was significantly longer than for CA1 patients (14.1 days) (p=0.01). There were no significant differences in mortality or wound complications. Hip fracture patients on clopidogrel can be safely operated on early provided they are medically stable. Bleeding risk should be borne in mind in those patients on dual therapy with aspirin.

Revision shoulder arthroplasty: does the stem really matter?

The management of a failed shoulder arthroplasty represents a complex and difficult problem for the treating surgeon, with potential difficulties and complications that are related to the need to remove a well-fixed stem. The aim of this study is to compare the intraoperative complications, postoperative complications, and outcome of revisions from stemmed arthroplasties (STAs) with those from surface replacement arthroplasties (SRAs). From 2005 to 2012, 40 consecutive revision shoulder arthroplasties were performed at our institute: 17 from STAs and 23 from SRAs. Perioperative events, operation time, blood loss, intraoperative fractures, and use of structural allograft were recorded. Clinical and radiologic outcomes were analyzed. Operation time, need for humeral osteotomy, need for structural allograft, and number of intraoperative fractures were significantly higher in the STA group. Blood loss, drop in hemoglobin level, need for blood transfusion, and hospitalization time were also higher in the STA group, but these differences were not statistically significant. Reoperation was performed in 3 patients in the SRA group. A significant clinical improvement was observed in both groups. The Constant score was higher in the SRA group. Revision of STAs is a more demanding procedure. The postoperative complication rate was slightly higher in the SRA group. The group with revision of SRAs showed slightly better clinical and radiographic results, but there was no statistically significant difference between the groups.

Diagnosis and management of splenic injury following colonoscopy: algorithm and case series.

Splenic injury following colonoscopy is a rare yet life-threatening complication. These injuries are often associated with delayed diagnosis and may require invasive intervention. We sought to study the emergent presentation associated with splenic injury post-colonoscopy and to suggest a new treatment algorithm. Six cases of splenic injury following colonoscopy were collected from three medical centers. Data regarding patient medical history, clinical presentation, laboratory and imaging findings and clinical management were recorded. A systematic PubMed/MEDLINE search was performed. Non-English-language publications and publications dating earlier than 2010 were excluded. An emergency department trauma-based management algorithm was designed according to the identified publications and review of the available trauma literature. The mean age was 65.3 years and the male-to-female ratio was 1:5. Five of the cases presented within 24 h of the colonoscopy complaining of severe abdominal pain. Hemodynamic instability was noted in four patients who presented with tachycardia (105-130), hypotension and/or a rapid drop in hemoglobin levels. All of the patients underwent initial resuscitation and a computerized abdominal tomography scan. Four of them required emergent splenectomy. No mortality or major morbidity was reported following the hospitalization. Although very rare, splenic injury during colonoscopy is an acute, severe and possible fatal complication. Patients may present with a rapid clinical deterioration and hemodynamic instability. Physicians should be familiar with the practical management of this surgical emergency and the treatment options available.

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Materials and methods: A retrospective and prospective study was carried out on 148 patients undergoing total knee replacement. 88 patients received tranexamic acid (10 mg/kg, iv) just before the cementation, 3 hours and 6 hours post operatively. 60 patients did not receive tranexamic acid. Perioperative blood loss was measured by the amount of post-operative drain, and drop in hemoglobin levels. The number of patients who needed blood transfusion and the number of units transfused was recorded and possible postoperative thromboembolic complications were studied clinically.

Interest of Prevention of Immediate Postpartum Hemorrhage with Misoprostol during Cesarean Section

Objective: The purpose of this study was to compare the efficacy of sublingual misoprostol to oxytocin for the prevention of Immediate Postpartum Hemorrhage (IPPH) during caesarian section in the Borgou Regional University Teaching Hospital (CHUDB). Methods: It was a prospective randomized controlled clinical trial conducted over a period of 6 months from January 26 to July 26, 2015, on 230 female patients meeting inclusion criteria: cesarean section on term singleton pregnancy, under spinal anesthesia, without any bleeding. The patients were selected at random and divided into two groups: the first group had received 600 micrograms (μg) of misoprostol by sublingual route during umbilical cord clamping; the second one was administered 20 UI of oxytocin through intravenous route. The primary endpoint was drop in hematocrit. The secondary endpoints were drop in hemoglobin level, perioperative blood loss and postoperative complications. Findings: The socio-demographic and obstetrical characteristics of both groups’ patients were comparable. Average drop in hematocrit was identical: 0.05 ± 0.04 in both groups (p=0.573). The same applies to mean hemoglobin level: 1.7 ± 1.2 g/dl (p=0.886). As well, no significant difference was noted in average blood loss between the misoprostol group and the oxytocin group, respectively 281.8 ± 124.4 ml and 282.2 ± 120.8 ml (p=0.271). The incidence of side effects such as fevers and chills was significantly higher in the misoprostol group, respectively (79.1% vs. 9.6% and 79.1% vs. 0.0% p<0.001). However, those side effects were tolerable. Conclusion: 600 μg of misoprostol dose by sublingual route is also as effective as oxytocin in the prevention of postpartum hemorrhage without significant side effects.

Transurethral enucleation of the prostate versus transvesical open prostatectomy for large benign prostatic hyperplasia: a systematic review and meta-analysis of randomized controlled trials

To evaluate the efficacy and safety of transurethral enucleation of the prostate (TUEP) versus transvesical open prostatectomy (OP) for the management of large benign prostatic hyperplasia (BPH). Randomized controlled trials (RCTs) comparing TUEP and OP were identified from PubMed, Embase and Web of Science up to February 28, 2015. A meta-analysis was conducted with the STATA 12.0 software. Nine RCTs including 758 patients were enrolled in our meta-analysis. There were no significant differences between the two groups in the maximum urinary flow rate at 1, 3, 6months, 1 and 2years: postvoiding residual urinary volume, prostate-specific antigen, international prostate symptom score and quality of life score at 1, 3, 6months and 1year; or international index of erectile function at 3, 6months and 1year. Perioperative outcomes including hemoglobin level drop, catheter period, irrigation length and hospital stay favored TUEP, while operative time and resected prostate weight favored OP. There was significantly less blood transfusion with TUEP, but no significant differences were found in other complications such as recatheterization, urinary tract infection, reintervention for clots and bleeding control, incidence of pneumonia and infarction, transient incontinence, bladder neck contracture, urethral stricture and recurrent adenoma. TUEP can be performed effectively and safely with functional outcomes and complications similar to OP for large BPH, whereas it has the advantages of a shorter catheter period, shorter hospital stays and less blood transfusion. These findings seem to support TUEP as the next-generation "gold standard" of surgery for large BPH.

Parvovirus B19 Infection Associated with Silent Cerebral Infarcts: A Secondary Analysis of the Silent Cerebral Infarct Trial Cohort

Introduction:Silent cerebral infarcts (SCI) are the major cause of neurological injury occurring in almost 40% of the population in children with sickle cell anemia (SCA); and are associated with a Full-Scale IQ decrease of approximately 5 points. Acute anemic events, defined as hemoglobin< 6.0 g/dl, is associated with an increase odds ratio (OR) of SCI (OR 2.72; 95% CI, 1.13-6.54; P = .025; Bernaudin et al. Blood. 2015 Mar 5; 125(10):1653-61). Infection with parvovirus B19 (B19V) causes a transient reticulocytopenia and an acute drop in hemoglobin levels in children with SCA. We tested the hypothesis that a history of B19V infection was associated with increased odds ratio of SCIs.Methods:In this retrospective cross-sectional study design, we performed a secondary analysis on the Silent Cerebral Infarct Multi-Center Clinical Trial (SIT Trial). Children with SCA between 5 and 15 years of age, with no history of overt strokes or seizures, were screened for SCIs with MRIs of the brain. Research personnel reviewed medical records to determine a history of B19V infection. Based on prior evidence from the SIT Trial cohort demonstrating that lower hemoglobin levels divided into tertiles are associated with an increase odds of SCI (DeBaun et al. Blood. 2012 Apr 19;119(16):3684-90), three analyses were performed. We stratified by hemoglobin levels into tertiles (<7.6g/dL, ³7.6 and ²8.4 g/dL, and >8.4 g/dL), to determine an association between SCI status and history of B19V infection. Chi squared statistic was used as the measure of association. As a secondary analysis of the original SIT trial cohort, the level of strong significance associated with an increased odds ratio of SCI was determined to be <0.01, with values <0.05 considered moderate significance.Results:A total of 814 of the SIT Trial participants had their SCI status adjudicated (present or absent) and a recorded history of B19V status (yes or no). In the cohort, 30% had a SCI and 17% had a history of B19V infection. Prior B19V infection with baseline hemoglobin levels <7.6 g/dL were associated with increase OR of SCI (OR 2.20; 95% CI, 1.22 to 3.97; p=0.008). Prior B19V infection with a baseline hemoglobin levels in the middle (³7.6 to²8.4 g/dL) and upper tertiles (> 8.4 g/dl) were not associated with an increased OR of SCI (OR 0.88; 95% CI, 0.47 to 1.66; p=0.695; and ³8.5 g/dL OR 1.39; 95% CI, 0.72 to 2.69; p=0.328; respectively).Conclusion:Children with SCA, a history of B19V and a low baseline hemoglobin level <7.6 g/dL have an increased OR of SCIs. Future efforts in developing a vaccine for B19V may provide an opportunity for decreasing the incidence of SCIs in children with SCA. DisclosuresNo relevant conflicts of interest to declare.

Effectiveness and Safety of Rivaroxaban in Treatment of Venous Thromboembolism in Cancer Patients

IntroductionPatients with active cancer have a high risk for venous thromboembolism (VTE). The current treatment of choice for cancer-associated thrombosis is low molecular weight heparin (LMWH). Evidence for the efficacy and safety of the target-specific oral anticoagulants in the prevention and treatment of cancer-associated thrombosis is limited. In the EINSTEIN trials, comparing rivaroxaban to LMWH plus a vitamin K antagonist, only a small number of patients with active cancer received treatment with rivaroxaban (6.8% [n=118] in EINSTEIN-DVT1 and 4.7% [n=114] in EINSTEIN-PE2). The use of rivaroxaban over LMWH for cancer-associated thrombosis is not recommended by the current guidelines.3 However, due to the parenteral route of administration and high cost burden of LMWH, some cancer patients at our institution have received rivaroxaban for cancer-associated thrombosis.MethodAn observational chart review was performed to determine the effectiveness and safety of rivaroxaban for the treatment of VTE in cancer patients by observing recurrent VTE and bleeding events. For the effectiveness endpoint, patients who received rivaroxaban for less than one month were excluded from the study. For the safety analysis, patients who received at least one dose of rivaroxaban were included in the study.ResultA total of 92 cancer patients with VTE who received rivaroxaban at Huntsman Cancer Institute were selected for the study. Median age was 60 years old and 54% (n=50) were male. Average estimated creatinine clearance at the initiation of rivaroxaban was 96.2 mL/min (range 31.8-241 mL/min, Cockcroft-Gault). Thirty-eight patients (41%) were treated for DVT (deep venous thromboses), 32 patients (35%) had PE (pulmonary embolism), and 19 patients (21%) had both DVT and PE.A total of 20 patients (21.7%) had a bleeding event while on therapy (see table). Ten patients (10.8%) experienced a major bleed and the median time to major bleeding was 4.4 months (IQR 2.4-11.6 months). One patient had a fatal intracranial bleed. Four patients (4.3%) had critical bleeding and 5 patients (5.4%) had a clinically relevant bleeding with ≥ 2g/dL drop in hemoglobin level and/or required ≥2 units of red blood cell transfusion. Pharmacodynamic interactions may have contributed to 3 major bleeds, including one patient on aspirin, another on ibuprofen, and the third patient on both aspirin and clopidogrel at the time of bleeding. Seven patients were taking rivaroxaban 20 mg daily at the time of the major bleed. The median platelet count at the time of bleeding was 170k/µL (IQR 108-333k/µL). One patient had a platelet count of 17 k/µL and was admitted with sepsis at the time of bleed. Ten patients (10.8%) experienced minor symptomatic bleeds and the median time to bleeding was 2.5 months (IQR 0.73-4.8 months).Only 4 patients (4.3%) experienced recurrent VTE while on rivaroxaban. Two patients had recurrent DVT. Two patients developed recurrent PE and both were admitted to the hospital for parenteral anticoagulation. The median time to recurrent VTE was 5.7 months (IQR 2.5-11 months). The median platelet count at the time of recurrence was 120 k/µL (range 26-216k/µL). One patient had a known thrombophilia, Factor V Leiden mutation.ConclusionThese data suggest that rivaroxaban may be a safe and acceptable alternative to LMWH for the treatment and secondary prevention of cancer-associated thrombosis. Table 1Huntsman Cancer Institute (n=92)EINSTEIN-DVT1(Cancer sub-group, n=118)EINSTEIN-PE2(Cancer sub-group, n=114)CLOT trial4(n=336)Major bleeding10.8% (n=10)14.4% (n=17)12.3% (n=14)14% (n=47)Clinically relevant non-major bleeding10.8% (n=10)Recurrent DVT2.2% (n=2)3.4% (n=4)n/a4.2% (n=14)Recurrent PE2.2% (n=2)n/a1.8% (n=2)3.9% (n=13)

Abstract 9955: Outcomes of Catheter Ablation of Atrial Fibrillation in Hypertrophic Cardiomyopathy Patients - A Pooled Analysis

Objectives: Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM.) Aggressive rhythm control is recommended for this group of patients and radiofrequency catheter ablation is emerging as a frontline strategy. This pooled analysis aims to study the efficacy and outcomes of AF ablation in HCM patients Methods: PubMed, EMBASE and Google Scholar databases were searched to identify all studies describing the outcomes of catheter ablation of AF in HCM. Data from identified studies was extracted and pooled analysis was carried out using CMA 2 software. Pooled adjusted procedure duration and incident rates of recurrence and adverse events were calculated using random effects model. Results: A total of 11 studies with 384 patients were included in this study. For the index procedure, mean procedural time, radio frequency ablation and fluoroscopy times were 207.3 minutes, 39.7 minutes and 62.4 minutes respectively. The adjusted incidence of major ablation-related complications (death, stroke, transient ischemic attack, peripheral embolism, cardiac tamponade or perforation, valvular damage, arteriovenous fistula requiring surgical intervention, and a large vascular access site hematoma resulting in a drop of hemoglobin level by 2 g/dL) was 4 per 100 procedures (95% CI 2.1 - 7.5%). The recurrence of AF after index ablation during the mean follow up period of 14.5 months occurred in 58% (95% CI 50 -66%) of the patients (Figure1). Conclusion: The results of our analysis suggest that there is a high rate of recurrence of AF in HCM patients who undergo single AF ablation. The risk of complications with AF ablation appears to be low in this group of patients. Further studies are needed to assess the impact of multiple ablations on long term outcomes in these patients.

Transient gastric ischemia as a complication of cystotomy in endoscopic pancreatic pseudocyst drainage

A 70-year-old man was referred to our department for endoscopic drainage of a pancreatic pseudocyst. He had acute pancreatitis as a result of choledocolithiasis, which developed following a cholecystectomy 2 years previously. Computed tomography (CT) revealed a 7-cm cystic lesion in the head of the pancreas, which was compatible with a pseudocyst. Endoscopic ultrasonography (EUS) was performed and showed a 7-cm homogeneous anechoic lesion. Under EUS guidance the lesionwas punctured using a 19-G needle through the posterior wall of the distal antrum (● Fig.1). After a guidewire had been passed into the cyst, cystotomywas performed. The access to the cyst was difficult, and during cystotomy ischemic changes were observed in the posterior wall andgreater curvature of the antrum (● Fig.2). The ischemia completely resolved after nearly 5 minutes. Complete cystotomy was achieved only after dissection of the fistula (● Fig.3) using a needleknife, which was inserted through an upper endoscope. Balloon dilation was performed, and two plastic 7-Fr doublepigtail stentswere placed● (Fig.4). The following day, the patient had fever and mild abdominal pain. CT scan showed the stent to be in a good position but an abscess was apparent between the stomach and the lesion, in the trajectory of the stent (● Fig.5). Antibiotic treatment with ciprofloxacin and metronidazole was initiated. Then, 3 days after the procedure, the patient experienced rectal bleeding, with a 4g/dL drop in hemoglobin levels (from 12.8 to 8.6g/dL). Upper endoscopy was performed, and showed a blood clot adherent to the stent, with no active bleeding. CT scan was repeated 1 week later, and showed resolution of the abscess. At this point, the patient resumed oral feeding and was discharged with no symptoms after 2 weeks of antibiotic treatment. Endoscopic drainage is an effective procedure for pancreatic pseudocyst [1]. Complications include stents migration, bleeding, perforation, and infection [2]. There have been no previous cases of gastric ischemia reported in the literature.

Factors predicting outcomes of micropercutaneous nephrolithotomy: results from a large single‐centre experience

To present our single-centre experience of the micropercutaneous nephrolithotomy (microperc) technique and define its role in the management of renal calculi as well as to analyse the factors predicting outcome. We retrospectively analysed data from 139 patients who underwent microperc for renal calculi between June 2010 and November 2014 at our institution. The factors analysed were demographic variables, which included age, sex, stone volume, stone density (Hounsfield units [HU]) and stone location, and intra- and peri-operative variables, such as operating time, drop in haemoglobin level, stone clearance and complications. The mean ± sd (range) patient age was 38.99 ± 17 years (9 months to 73 years), stone volume was 1 095 ± 1 035 (105-6 650) mm(3) and stone density was 1 298 ± 263 HU. The mean ± sd (range) operation duration was 50.15 ± 9.8 (35-85) min, hospital stay was 2.36 ± 0.85 (2-5) days and drop in haemoglobin level was 0.63 ± 0.84 (0-3.7) mg/dl. Eight patients had renal colic that was managed by antispasmodic medication, four patients had renal colic severe enough to warrant JJ stenting and three patients had urinary tract infections which were managed with appropriate antibiotics. We were able to complete microperc in 130 patients, with 119 (91.53%) patients being rendered completely stone-free, while in 11 patients (8.46%) there were some residual fragments seen on imaging. On multivariate analysis, stone number, volume and density were found to be significant predictors of clearance. Conversion to mini- or standard percutaneous nephrolithotomy was required in nine patients (6.47%), with intra-operative complications and stone number being the significant factors warranting conversion on a multivariate basis. The outcomes in the present study suggest that microperc is a promising treatment method for solitary renal stones with volumes <1 000 mm(3) and stones with low density (HU), regardless of stone location. In the present series we achieved a high success rate with low morbidity; however larger, prospective and comparative studies from multiple centres are required to further establish the role of microperc in the management of renal calculi.

Application of nephrostomy tubes with balloon after percutaneous nephrolithotomy: A randomized controlled clinical trial.

To evaluate the effect of nephrostomy tubing with balloon on postoperative hemorrhage after percutaneous nephrolithotomy. A total of 284 patients with upper urinary calculi were enrolled for blocked randomization with 71 blocks and block length of 4. The experimental group consisted of 143 patients receiving 14-Fr silicone tubing with balloon, and the control group consisted of 141 patients receiving 14-Fr silicone tubing without balloon. One patient in the control group developed intraoperative bleeding as a result of calyceal laceration, and was reassigned to the experimental group receiving nephrostomy tubing with balloon. Postoperative drop in hemoglobin level at 3 days was significantly less in the experimental group (3.31 ± 2.85 g/L) compared with the control group (5.14 ± 3.43 g/L) (P < 0.001). The duration of gross hematuria, defined by urine with visible light or bright red color (2.73 ± 1.59 days vs. 3.55 ± 2.09 days, P < 0.001), and the incidence of postoperative extravasation (22/143 vs. 38/141, P < 0.05) for patients in the experimental group (implanted with 14-Fr silicone tubing with balloon) were significantly lower compared with the control group. Use of indwelling nephrostomy tubes with balloon after percutaneous nephrolithotomy can reduce blood loss. Further consideration for more widespread adoption of this type of tubing to limit perioperative bleeding complications is warranted.

What Is the Benefit of Tranexamic Acid vs Reinfusion Drains in Total Joint Arthroplasty?

We sought to compare the efficacy and cost of reinfusion drains vs tranexamic acid (TA) in primary total joint athroplasty (TJA) patients. We randomized 186 primary TJAs (71 hips, 115 knees) to standard drains (61/186), autologous reinfusion drains (60/186), or single dose (20 mg/kg) of TA (65/186). There was a statistically significant (P < .0001) less drop in hemoglobin levels (2.98 mg/dL; range, 0.5-6.10) in the TA group compared with standard drains (P < .0001) and reinfusion drains (P < .0061). There was no significant difference in transfusion rates. At $581.89, the unit cost of the reinfusion system is substantially higher than the standard drain ($7.56) and TA ($35.91/g). The results of this randomized controlled trial demonstrate that TA is more efficacious and provides cost savings compared with reinfusion drains as a blood management tool for TJA.

Intra-articular administration of tranexamic acid in total hip arthroplasty.

To evaluate the effectiveness of intraarticular tranexamic acid (TXA) in reducing blood loss and the need for blood transfusion during total hip arthroplasty (THA). Records of 19 men and 31 women aged 46 to 83 (mean, 62) years who underwent primary THA with intra-articular administration of TXA were reviewed. They were compared with a matched cohort of 17 men and 33 women aged 40 to 87 (mean, 62) years who underwent the same procedure by the same surgeon without use of TXA. Postoperatively, a standard thromboembolic prophylaxis protocol was followed. A serum haemoglobin level of <80 g/l was the trigger for blood transfusion. The 2 groups were comparable in terms of age, gender, body mass index, side involved, and anaesthesia method. No patient developed infection, wound haematoma, symptomatic deep vein thrombosis, or pulmonary embolism within 30 days. Compared with controls, patients in the TXA group had a higher median postoperative serum haemoglobin level (103 vs. 112 g/l, p=0.013), lower median drop in serum haemoglobin level (31 vs. 20 g/l, p<0.001), lower median total blood loss (900 vs. 575 ml, p<0.001), and lower transfusion rate (32% vs. 10%, p=0.007). The TXA treatment cost S$19.50 per patient, whereas one unit of allogenic blood cost S$123 per patient. Respectively in the control and TXA groups, the mean cost per patient was S$39.36 and S$31.80, indicating a 19% difference. Intra-articular administration of TXA is a cost-effective and safe means to reduce blood loss and the need for blood transfusion during THA, without increasing the risk of thromboembolic events.

Adnexectomy by poor man’s transvaginal NOTES

The purpose of this study was to demonstrate the feasibility and safety of adnexectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign adnexal masses. Conventional, reusable laparoscopic instruments were used, inserted through aninexpensive, self-constructed single port device. Between November 2013 and November 2014, 20 adnexectomies by vNOTES were performed by a single surgeon (BJ). Only conventional, reusable laparoscopic instruments were used. The self-constructed single port device was made by assembling a surgical glove, a wound protector, one reusable 10-mm trocar, and four reusable 5-mm trocars. The adnexectomy was performed according to the technique for standard laparoscopic surgery, and the specimen was removed through the colpotomy incision. Patient and perioperative data were analysed. Twenty patients underwent adnexectomy by vNOTES, and no conversion to standard laparoscopy or laparotomy was necessary. Mean operation time was 32 min (20–50 min); mean drop in hemoglobin level was 0.9 g/dl (0–2.1 g/dl). There were no operative complications. Post-operative pain scores were very low. The mean size of the removed adnexal mass was 51.8 mm (35–110 mm). Adnexectomy by vNOTES is feasible even for masses up to 110 mm and even when performed with reusable, conventional laparoscopic instruments. The main advantages of vNOTES are better cosmetics, low postoperative pain scores and easy removal of the specimen without spillage. This frugally innovative technique also enables surgeons to perform adnexectomies by vNOTES in low resource settings.

Prospective randomised trial comparing unlinked, modular bicompartmental knee arthroplasty and total knee arthroplasty: A five years follow-up

BackgroundA significant proportion of patients with knee osteoarthritis have articular degeneration that is limited to the medial and patellofemoral compartments. The objective of this study was to compare clinical outcomes of unlinked bicompartmental knee arthroplasty (BCA) and total knee arthroplasty (TKA) at 5years in this subset of patients. Methods48 patients were randomised into two groups: unlinked, modular bicompartmental arthroplasty and total knee arthroplasty. Data on demographics and clinical outcomes were collected (Bartlett Knee Score, Oxford Knee Score, Knee Society Score). Data on intra-operative blood loss in both groups were also recorded. ResultsOut of the 48 patients, 26 underwent BCA and 22 had TKA. Both groups shared similar demographic profiles. At five years post surgery, there was significant improvement across all functional scores in both groups. However, there was no significant difference in outcome scores in the BCA group compared to the TKA group. The drop in serum haemoglobin levels postoperatively was 1.55 and 2.30g/dl for the BCA and TKA groups respectively (p<.001). The total amount of blood loss was 397 and 647ml respectively (p=.001). ConclusionsUnlinked, modular BCA results in similar clinical and functional scores as TKA for medial and patellofemoral arthritis in the mid-term. Intra-operative blood loss was significantly lower in the BCA group compared to the TKA group. BCA is a viable option for a select group of young and active patients with the advantage of reduced intra-operative blood loss and equivalent functional outcomes as TKA.