Early Hematoma Research Articles

SAT0564 Cytotoxic T-Lymphocyte Antigen-4 (CTLA-4) Expressed in Human Mesenchymal Stromal Cells

BackgroundThe Cytotoxic T-Lymphocyte Antigen-4 (CTLA-4) is an inhibitory costimulatory molecule of the CD28 family, predominantly found on both regulatory T cells and activated T cells. It plays a crucial role...

Time Course of Early Postadmission Hematoma Expansion in Spontaneous Intracerebral Hemorrhage

Early hematoma expansion (EHE) in patients with intracerebral hematoma is a promising treatment target. To date, the time course of EHE has remained poorly described. We prospectively investigated the time course of EHE. We included consecutive patients presenting spontaneous intracerebral hematoma within 4.5 hours. On admission, patients underwent noncontrast computed tomography (CT) and CT angiography. Serial hematoma volume estimations by transcranial B-mode ultrasound were effected through the contralateral transtemporal bone window by obtaining sagittal, transversal, and coronal diameter and calculating the ABC/2-formula. National Institute of Health Stroke Scale and transcranial B-mode ultrasound were performed consecutively every 30 minutes during the first 6 hours and from 6 to 12 hours every 2 hours. Follow-up CT and ultrasound were performed after ≈24 hours. Twenty-five patients with intracerebral hematoma were included; mean (SD) time from onset to CT was 108.6 (45.7) minutes. Ten (40%) patients had EHE. In patients with a final clinically significant hematoma expansion >12.5 mL, all EHE occurred within 6 hours after admission scan. EHE in spot sign positive patients continued during the first 5 hours after CT angiography. In spot sign-negative patients, no significant EHE was observed (Friedman test, P=0.476). Neurological deterioration occurred in 5 (20%) patients and was well temporally correlated with EHE. Transcranial B-mode ultrasound demonstrated good volume estimation compared with the follow-up CT with a maximum absolute volume deviation within 7 mL and minimal systematic error (mean deviation, 1.3 [confidence interval, -0.1 to 2.6] mL). EHE was reliably reflected by transcranial B-mode ultrasound and mainly occurred within the first 7 to 8 hours after symptom onset. http://www.clinicaltrials.gov. Unique identifier: NCT01472224.

Abstract 204: Xe-Loaded Liposome Reduces Bleeding With Neuroprotection From Early Injury in Subarachnoid Hemorrhagic Stroke

Background: Cell death, especially apoptosis occurs in subarachnoid hemorrhage (SAH) due to rapid and massive brain injury from the initial bleeding. Xe-loaded echogenic liposomes (Xe-ELIP) have been reported to have hemostatic effects in SAH. The goals of this study were to quantity the effect of Xe-ELIP on hemorrhage volume and also to evaluate its neuroprotective effects using a SAH brain injury model. Methods: Xe-ELIP were prepared by a pressurization-freeze method. SAH was induced in Sprague-Dawley rats by endovascular perforation. Rats (n=18) were randomly divided into SAH, SAH with ELIP treatment and SAH with Xe-ELIP treatment groups. Treatments were administrated intravenously at 30 minutes after SAH. Ultrasound was applied over the common carotid artery to trigger Xe release from circulating Xe-ELIP. Hemorrhage volume was quantified by spectrophotometric hemoglobin assay at two hours after SAH. Expression of caspase-3 and positive TUNEL was examined as markers for apoptosis. Results: SAH without treatment had the greatest hemorrhage volume (327 ± 25μl); the hemorrhage volume in SAH with ELIP treatment group was 274 ± 37μl (p=0.27 vs. no treatment); Xe-ELIP treatment decreased hemorrhage volume to 165 ± 9μl (p<0.001 vs. no treatment; p=0.026 vs. ELIP treatment). Xe-Elip treatment was also associated with reduced inflammation, suppressed TUNEL positive and caspase-3 staining in the cerebral cortex, and improved neurological testing. Conclusions: Early hematoma growth in subarachnoid hemorrhagic stroke correlates with early brain injury. Xe-loaded liposomes minimizes hemorrhage volume and improves neurological outcomes in SAH. The underline mechanism of Xe hemostasis may relate to its cytoprotectant and anti-inflammatory effects.

Preperitoneal surgery using a self-adhesive mesh for inguinal hernia repair.

Background and Objectives:Laparoscopic preperitoneal hernia repair with mesh has been reported to result in improved patient outcomes. However, there are few published data on the use of a totally extraperitoneal (TEP) approach. The purpose of this study was to present our experience and evaluate early outcomes of TEP inguinal hernia repair with self-adhesive mesh.Methods:This cohort study was a retrospective review of patients who underwent laparoscopic TEP inguinal hernial repair from April 4, 2010, through July 22, 2014. Data assessed were age, sex, body mass index (BMI), hernia repair indications, hernia type, pain, paresthesia, occurrence (bilateral or unilateral), recurrence, and patient satisfaction. Descriptive and regression analyses were performed.Results:Six hundred forty patients underwent laparoscopic preperitoneal hernia surgery with self-adhesive mesh. The average age was 56 years, nearly all were men (95.8%), and the mean BMI was 26.2 kg/m2. Cases involved primary hernia more frequently than recurrent hernia (94% vs 6%; P < .05). After surgery, 92% of the patients reported no more than minimal pain, <1% reported paresthesia, and 0.2% had early recurrence. There were 7 conversions to an open procedure. The patients had no adverse reactions to anesthesia and no bladder injury. Postoperative acute pain or recurrence was not explained by demographics, BMI, or preoperative pain. There were significant associations of hernia side, recurrence, occurrence, and sex with composite end points. Nearly all patients (98%) were satisfied with the outcome.Conclusion:The use of self-adhesive, Velcro-type mesh in laparoscopic TEP inguinal hernia repair is associated with reduced pain; low rates of early recurrence, infection, and hematoma; and improved patient satisfaction.

Aggressive Blood Pressure Control in Intracerebral Hemorrhage (the Abc-Ich Study)—A Pilot Study

Spontaneous intracerebral hemorrhage (ICH) accounts for one fifth of all strokes and is associated with an extremely high rate of morbidity and mortality. Affecting greater than 1 million people a year, ICH will leave the majority of its’ patients significantly disabled or dead. An initially high systolic blood pressure upon presentation is associated with hematoma expansion, peri-hema- toma expansion, and increased mortality. The relationship between blood pressure, the degree of blood pressure control and hematoma expansion has yet to be defined, but the literature has ob- served a relationship between tightly controlled blood pressures and decreased hematoma expansion. There have been many proposed mechanisms to explain this effect. Larger initial hematomas may lend greater hydrostatic forces and this could result in greater total hematoma volume, and greater surrounding edema. Recent literature has suggested that blood pressure reductions in acute ICH may be tolerated because of reduced metabolism, and preserved autoreguation in the peri-hematoma region. The volume of the hematoma is a critical determinant of mortality and functional outcome after intracerebral hemorrhage, and early hematoma growth is an important cause of neurologic deterioration. An increase in volume of more than thirty-three percent is detectable on repeated computed tomography (CT) in thirty-eight percent of patients initially scanned within the first three hours of onset of symptoms; in two thirds of these cases this change is noticeable on CT within the first hour. This supports the hypothesis that early aggressive blood pressure optimization would decrease hematoma size and edema. This is further supported by the fact that patients with high blood pressure and acute intracerebral hemorrhage have worse outcomes than their counterparts. We hypothesize that prompt and aggressive, early blood pressure reduction in emergency department patients with acute spontaneous intracerebral hemorrhage will result in a reduction of early hematoma growth. The study institution is a large urban emergency department and tertiary care stoke center, with over 55,000 emergency department visits per year. This prospective cohort study compared the results and outcomes observed within the enrolled prospective study population, to the results and outcomes of a matched historical cohort population (future patients with intracranial hemorrhage that did not receive the ABC-ICH protocol). Methods and Material: A nicardipine infusion was administered to optimize blood pressure in all patients presenting with intracerebral hemorrhage with a target mean arterial pressure (MAP) of 80 - 110. Hematoma volume (primary outcome measure) was measured on cat scans at time of presentation and at twenty-four hours. The hematoma volume in the enrolled prospective study population was compared to those of a matched cohort (patients with intracranial hemorrhage that did not receive the ABC-ICH protocol following the conclusion of the study). Results: One hundred total patients were enrolled into the study. Fifty patients were enrolled prospectively in the study and matched to a similar group of fifty cohort patients. The difference in the mean change of hematoma volume at twenty-four hours was 7.29 ml (control) and 2.84 ml (study). The result was an absolute decrease in hematoma size of 4.45 ml in the group treated aggressively with nicardapine for blood pressure reduction within one hour of their initial presentation. Conclusions: These results support the previous research suggesting that aggressive blood pressure control in intracerebral hemorrhage reduces hematoma growth, however the clinical benefit of such a reduction will have to be evaluated in ongoing research.

Extent of Decompression and Incidence of Postoperative Epidural Hematoma Among Different Techniques of Spinal Decompression in Degenerative Lumbar Spinal Stenosis

Prospective radiographic cohort study. To study the extent of bony decompression and dural sac expansion after laminectomy (including subtotal laminectomy and laminotomy with midline resection), bilateral fenestration, and unilateral fenestration with contralateral undercutting in lumbar spinal canal stenosis. Further, to investigate differences of incidence and extent of early postoperative epidural hematoma in these approaches. There are different techniques of decompression in lumbar spinal stenosis. An overall good clinical outcome has been reported with different biomechanical consequences, but no morphometric comparative reports exist on these approaches. Using the data of a previous prospective study of 30 patients, who underwent lumbar decompression for degenerative stenosis, 49 levels treated with 3 different kinds of surgical approaches were analyzed: (1) laminectomy (including subtotal laminectomy, laminotomy with midline resection); (2) bilateral fenestration; and (3) unilateral fenestration with contralateral undercutting. In all 3 groups, the cross-sectional area of the maximum bony stenosis and dural sac compression (bony margins and dural sac expansion) were measured in each operated level before and after the operation. Occurrence of epidural hematoma and its size were noted in the 3 groups. Median postoperative bony stenosis was not significantly different in the groups, being 330 mm(2), 333.5 mm(2), and 261.5 mm(2), respectively, in groups 1, 2, and 3. There was no statistically significant difference between the median postoperative extension of dural sac areas in the 3 groups, measuring 125 mm(2), 123 mm(2), and 137 mm(2). The incidence of epidural hematoma was similar in the 3 groups. Levels where postoperative epidural hematoma was detected had larger bony decompression independent of the surgical approach compared with the whole group. Unilateral and bilateral approaches achieve a similar amount of dural sac extension by a lesser extent of bony resection in comparison with the laminectomy approach. There is a tendency of increased postoperative hematoma in approaches with greater bony decompression area.

Advances in CT for prediction of hematoma expansion in acute intracerebral hemorrhage

Intracerebral haemorrhage accounts for 10–15% of all strokes and is associated with high morbidity and mortality. Early hematoma expansion, which occurs in approximately a third of patients leads to worse outcomes. Prediction of expansion may aid in the identification of patients most likely to benefit from novel medical or surgical therapies. Intrahematoma contrast density seen on CT angiography, coined the ‘spot sign’, has been validated in a prospective multicenter study to predict expansion and poor outcome. Increasing the number of spot signs visualized increases the risk of expansion. Utilization of delayed or dynamic contrast-enhanced CT is able to detect up to 21% additional patients with contrast extravasation, and improves sensitivity for outcome prediction. Different patterns of contrast extravasation may indicate differential rates of hemorrhage. CT angiography or dynamic contrast-enhanced CT imaging may aid in identifying efficacious therapies in intracerebral haemorrhage, and identification ...

C-Reactive Protein Predicts Hematoma Growth in Intracerebral Hemorrhage

Early hematoma growth (EHG) occurs in about one third of patients with spontaneous intracerebral hemorrhage. The main aim of this study was to investigate the potential of plasma C-reactive protein (CRP) for predicting EHG after acute spontaneous intracerebral hemorrhage. Plasma CRP was measured within 6 hours of onset (median, 120 minutes) in 399 patients with primary or vitamin K antagonist-associated spontaneous intracerebral hemorrhage and without recent infection. Computed tomography brain scans were performed at baseline and repeated within 24 hours (median, 22 hours). The primary outcome was EHG, defined as absolute growth>12.5 cm3 or relative growth>33%. Secondary outcomes included early neurological worsening (ENW) using the Glasgow Coma Scale and 30-day mortality. Multivariable regression analyses were used to evaluate associations of CRP concentration and outcomes. Kaplan-Meier analysis was used for survival. EHG occurred in 25.8%, ENW in 19.3%, and mortality was 31.8% at 30 days. Thirty-day mortality was significantly higher in patients with ENW (hazard ratio, 3.21; 95% confidence interval, 2.00-5.17; P<0.0001) and in patients with EHG (hazard ratio, 2.13; 95% confidence interval, 1.42-3.18; P<0.0001, log-rank test). Median CRP was 12 mg/L (interquartile range, 10-17) in the EHG group and 7 mg/L (interquartile range, 4-12.1) in those without EHG (P<0.0001). In multivariable analyses, plasma CRP>10 mg/L independently predicted EHG (odds ratio, 4.71; 95% confidence interval, 2.75-8.06; P<0.0001) and ENW (odds ratio, 2.70; 95% confidence interval, 1.50-4.84; P=0.0009). CRP>10 mg/L is independently predictive of EHG and ENW, both of which are associated with increased mortality. Inflammation may be important in contributing to EHG and warrants further investigation.

Subphrenic hematoma after thoracoscopic discectomy: description of a very rare adverse event and review of the literature on complications

The authors describe a very rare and previously unreported complication of thoracoscopic discectomy. Endoscopic spine surgery has evolved as a safe and effective treatment, and thoracoscopic discectomy, in particular, provides several advantages over open approaches, although it can be associated with intraoperative or postoperative complications. The most frequently observed adverse events are intercostal neuralgia, retained disc fragments, durotomies, atelectasis, extensive bleeding, and emergency conversion to open thoracotomy for vascular injuries. Even rare complications, such as chylorrhea or brain hemorrhagic infarction, have been reported. Nonetheless, a literature review did not reveal any case of postoperative intraabdominal hematoma following thoracoscopic discectomy. A 43-year-old woman, with no history of hematological or vascular disorders or thoracic surgery, underwent a right-sided thoracoscopic discectomy for T11-12 disc herniation. No apparent surgical technique-related complications were encountered, but intermittently repeated difficulties with single-lung ventilation occurred. The resultant dysventilation allowed partial right lung reexpansion, along with increased abdominal pressure. The latter induced an upward ballooning of the right diaphragm with consequent obstruction of the surgical field of view, requiring constant and continuous pressure applied to the thoracic surface of the diaphragm via a metal fan retractor and thus counteracting the increased abdominal pressure. Postoperatively, a large subdiaphragmatic hematoma originating from a bleeding right inferior phrenic artery was diagnosed and required urgent endovascular occlusion. The patient made an uneventful recovery with conservative treatment. A very rare and previously unreported complication-that is, early subdiaphragmatic hematoma after thoracoscopic discectomy-is described here. The authors submit that conversion to an open approach is safer when persistent anesthesia-related complications are encountered in thoracoscopic discectomy.

Trauma

The August 2013 Trauma Roundup360 looks at: reverse oblique fractures do better with a cephalomedullary device; locking screws confer no advantage in tibial plateau fractures; it’s all about the radius of curvature; radius of curvature revisited; radial head replacement in complex elbow reconstruction; stem cells in early fracture haematoma; heterotrophic ossification in forearms; and Boston in perspective.

MRI diffusion-weighted imaging in intracranial hemorrhage (ICH)

PurposeTo assess the role of MRI DWI in detection and characterization of ICH. Patients and methods61 patients with intracranial hemorrhage who underwent MRI (including DWI, ADC, and GRE) and CT were retrospectively included in this study. MRI DWIs were analyzed for age, type, (primary parenchymal hemorrhage or hemorrhagic lesion) and location of the hemorrhage. The results were compared with conventional MRI sequences, GRE, and CT to assess the diagnostic accuracy of DWI in assessment of patients with intracranial hematoma. ResultsWe had 61 patients with intracranial hemorrhage, six cases were missed by DWI. MRI DWI was accurate for the detection of hyperacute, medium, large sized acute, early and late sub acute, subdural, hemorrhagic components of arterial and venous infarction, intraventricular hemorrhage. DWI showed low sensitivity in detection of subarachnoid and small intraparenchymal hemorrhage The ADC measurements in hyperacute, acute, early and late subacute hematoma were statistically equivalent and were significantly less than the late subacute hematoma as well as the contralateral white matter. ConclusionMRI DWI was accurate in detection, characterization and staging hyperacute, acute, subacute hemorrhage as well as hemorrhagic components of arterial and venous infarctions and of low diagnostic accuracy in subarachnoid and small parenchymal hemorrhage.

OP0105 Accumulation of CD34+ hematopoietic stem cells in the initial inflammatory human fracture hematoma is driven by rantes and eotaxin

BackgroundWe have previously shown the early phase of human fracture healing to be characterized by hypoxia which promotes inflammation and chemoattraction. Hypoxia is also known to promote proliferation, survival and...

SP0119 Biomechanical and Immunological Aspects of Fracture Healing: Update 2013

The initial events after fracture seem to be essential for fast and uneventful bone healing. Tissue organization (e.g. invasion of vessels) starts early, leading to a restructuring of the hematoma....

Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial

SummaryBackgroundThe balance of risk and benefit from early neurosurgical intervention for conscious patients with superficial lobar intracerebral haemorrhage of 10–100 mL and no intraventricular haemorrhage admitted within 48 h of ictus is unclear. We therefore tested the hypothesis that early surgery compared with initial conservative treatment could improve outcome in these patients.MethodsIn this international, parallel-group trial undertaken in 78 centres in 27 countries, we compared early surgical haematoma evacuation within 12 h of randomisation plus medical treatment with initial medical treatment alone (later evacuation was allowed if judged necessary). An automatic telephone and internet-based randomisation service was used to assign patients to surgery and initial conservative treatment in a 1:1 ratio. The trial was not masked. The primary outcome was a prognosis-based dichotomised (favourable or unfavourable) outcome of the 8 point Extended Glasgow Outcome Scale (GOSE) obtained by questionnaires posted to patients at 6 months. Analysis was by intention to treat. This trial is registered, number ISRCTN22153967.Findings307 of 601 patients were randomly assigned to early surgery and 294 to initial conservative treatment; 298 and 291 were followed up at 6 months, respectively; and 297 and 286 were included in the analysis, respectively. 174 (59%) of 297 patients in the early surgery group had an unfavourable outcome versus 178 (62%) of 286 patients in the initial conservative treatment group (absolute difference 3·7% [95% CI −4·3 to 11·6], odds ratio 0·86 [0·62 to 1·20]; p=0·367).InterpretationThe STICH II results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral haemorrhage without intraventricular haemorrhage.FundingUK Medical Research Council.

Computed Tomography Angiography Spot Sign Does Not Predict Case Fatality in Aneurysmal Subarachnoid Hemorrhage With Intraparenchymal Extension

Many patients with aneurysmal subarachnoid hemorrhage (SAH) with intraparenchymal extension develop early hematoma expansion, which is not explained by aneurysmal rerupture in half of cases. In patients with primary intracerebral hemorrhage, the computed tomography angiography (CTA) spot sign predicts hematoma expansion and poor outcome. We conducted a 2-center prospective cohort study to evaluate whether CTA spot sign predicts case fatality in aneurysmal subarachnoid hemorrhage with intraparenchymal extension. We studied consecutive patients with aneurysmal subarachnoid hemorrhage with intraparenchymal extension. Two experienced readers, blinded to clinical data, analyzed CTAs for spot sign presence. We assessed the proportion of patients with the CTA spot sign and tested its association with in-hospital and 90-day case fatality, using univariable and multivariable logistic regression. In 32 of 236 patients (14%), we found at least 1 spot sign. Acute surgical hematoma evacuation with aneurysm occlusion occurred in 120 patients (51%). The overall in-hospital case fatality rate was 37%. The CTA spot sign was not associated with in-hospital (multivariable odds ratio, 0.51 [95% confidence interval, 0.06-3.26]) or 90-day (multivariable odds ratio, 0.59 [0.21-1.65]) case fatality. The found frequency of CTA spot signs is lower after aneurysmal than primary intracerebral hemorrhage and is not associated with in-hospital or 90-day case fatality in patients with aneurysmal subarachnoid hemorrhage with intraparenchymal extension.

Human immune cells' behavior and survival under bioenergetically restricted conditions in an in vitro fracture hematoma model

The initial inflammatory phase of bone fracture healing represents a critical step for the outcome of the healing process. However, both the mechanisms initiating this inflammatory phase and the function of immune cells present at the fracture site are poorly understood. In order to study the early events within a fracture hematoma, we established an in vitro fracture hematoma model: we cultured hematomas forming during an osteotomy (artificial bone fracture) of the femur during total hip arthroplasty (THA) in vitro under bioenergetically controlled conditions. This model allowed us to monitor immune cell populations, cell survival and cytokine expression during the early phase following a fracture. Moreover, this model enabled us to change the bioenergetical conditions in order to mimic the in vivo situation, which is assumed to be characterized by hypoxia and restricted amounts of nutrients. Using this model, we found that immune cells adapt to hypoxia via the expression of angiogenic factors, chemoattractants and pro-inflammatory molecules. In addition, combined restriction of oxygen and nutrient supply enhanced the selective survival of lymphocytes in comparison with that of myeloid derived cells (i.e., neutrophils). Of note, non-restricted bioenergetical conditions did not show any similar effects regarding cytokine expression and/or different survival rates of immune cell subsets. In conclusion, we found that the bioenergetical conditions are among the crucial factors inducing the initial inflammatory phase of fracture healing and are thus a critical step for influencing survival and function of immune cells in the early fracture hematoma.

A practical prediction model for early hematoma expansion in spontaneous deep ganglionic intracerebral hemorrhage

ObjectiveEarly hematoma expansion is a known cause of morbidity and mortality in patients with intracerebral hemorrhage (ICH). The goal of this study was to identify clinical predictors of ICH growth in the acute stage. Materials and methodsWe studied 201 patients with acute (<6h) deep ganglionic ICH. Patients underwent CT scan at baseline and hematoma expansion (>33% or >12.5ml increase) was determined on the second scan performed within 24h. Fourteen clinical and neuroimaging variables (age, gender, GCS at admission, hypertension, diabetes mellitus, kidney disease, stroke, hemorrhagic, antiplatelet use, anticoagulant use, hematoma density heterogeneity, hematoma shape irregularity, hematoma volume and presence of IVH) were registered. Additionally, blood pressure was registered at initial systolic BP (i-SBP) and systolic BP 1.5h after admission (1.5h-SBP). The discriminant value of the hematoma volume and 1.5h-SBP for hematoma expansion were determined by the receiver operating characteristic (ROC) curves. Factors associated with hematoma expansion were analyzed with multiple logistic regression. ResultsEarly hematoma expansion occurred in 15 patients (7.0%). The cut-off value of hematoma volume and 1.5h-SBP were determined to be 16ml and 160mmHg, respectively. Hematoma volume above 16ml (HV>16) ([OR]=5.05, 95% CI 1.32–21.36, p=0.018), hematoma heterogeneity (HH) ([OR]=7.81, 95% CI 1.91–40.23, p=0.004) and 1.5h-SBP above 160mmHg (1.5h-SBP>160) ([OR]=8.77, 95% CI 2.33–44.56, p=0.001) independently predicted ICH expansion. If those three factors were present, the probability was estimated to be 59%. ConclusionsThe presented model (HV>16, HH, 1.5h-SBP>160) can be a practical tool for prediction of ICH growth in the acute stage. Further prospective studies are warranted to validate the ability of this model to predict clinical outcome.

Breast Augmentation: Procedure, Complications &amp; Treatment.

Breast Augmentation is one of the most common aesthetic procedures performed with a very high satisfactionrate. After the description of first report of implant placement in 1964 by Cronin and Gerow, the popularity of theprocedure is on the rise. The complications are few but require thorough understanding of each one of them fortheir prompt management and treatment. The procedure is generally performed by a prosthesis or implant.These implants are available in different sizes, shapes and profile and the surface of implant shell can be textured, micro textured or smooth with advantages to each type.Procedure can be performed through submammary, intra-areolar, axillary or transumblical approach. These implants can be placed in partial submuscular, dual plane, muscle splitting biplane, subfascial and subglandularpockets with advantages to each.In this chapter, over 1700 breast augmentations performed by the author were reviewed. All procedures wereperformed under general anaesthetic. Textured and smooth surface implants were used and using intra-areolaror submammary incisions, the devices were placed in partial submuscular, subglandular and muscle splitting biplane. All patients had at least single intravenous antibiotic and most of the procedures were performed as daycases.Complications following breast augmentation are few and may present early or late. Early common complicationsare haematoma, seroma, infection and Mondors’ Disease. Late complications include capsular contracture, implant rupture, malplacement of implant, dynamic breasts, implant flipping and rippling of the implant etc.The management and treatment of these complications were assessed and out come evaluated.Synmastia, bottoming down, periprosthetic infection and dynamic deformities are revisited and their treatmentplans redefined. Mondors disease incidence, asymptomatic as well as symptomatic, was researched and its various presentations associated with breast augmentation described. Implant rupture, its association with qualityand handling was reviewed. Implant rupture, its presentation and treatment plan redefined. Relationship of infection to length of antibiotic is analysed and various treatment modalities of periprosthetic infection and their outcome was assessed and suggestions and strategies for their management outlined.Breast augmentation is a procedure with a very high satisfaction rate however complications arising followingaugmentations needs to be carefully evaluated and require a proactive and appropriate action plan. An informedconsent should ideally include information outlining benefits of breast augmentation, possible complicationsalong with the management plan of each one of them.

Subclavian vein puncture vs. surgical cut-down to the cephalic vein for insertion of totally implantable venous access ports

Totally implantable venous access ports (TIAP) are commonly used in oncology, but which insertion modality should be preferred is still discussed controversially. We present a retrospective survey of the two main approaches for central venous cannulation from a single surgical department. All TIAP procedures between January 2004 and December 2010 were included. Direct puncture of the subclavian vein (DP) represented the standard approach for port insertion until 2007, when surgical cut-down to the cephalic vein (CD) was introduced as a reliable alternative at our department. Primary success rate, procedure time and postoperative complications within 30 days were analysed. In 301 (64.9 %) cases, DP was performed, and CD was done 163 times. Primary success rate for DP and CD was 94.4 and 87.1 %, respectively (p = 0.012). Mean procedure time was significantly longer in the CD group (38 vs. 32 min; p = 0.008). On routine postoperative chest X-ray, pneumothoraces were seen only following DP (10/301; 3.3 %), twice (2/301; 0.7 %) necessitating drainage. Early port infection (n = 6), haematoma (n = 2) and inadvertent arterial placement (n = 1) were seen following DP only. Complication rate for DP and CD procedures accounted for 7 and 1.2 %, respectively (p = 0.006). Surgical CD is associated with a minimal risk for (severe) early complications and should be favoured over DP for TIAP implantation even if it takes longer and is associated with a lower primary success rate

Prothrombin complex concentrates to reverse warfarin-induced coagulopathy in patients with intracranial bleeding

Prothrombin complex concentrates (PCCs) offer a means for the rapid reversal of warfarin, particularly in the setting of life-threatening bleeding. We evaluated the effectiveness and safety of a PCC-based protocol in patients with warfarin-associated intracerebral hemorrhage (ICH), subdural hematoma (SDH), or subarachnoid hemorrhage (SAH).This was a retrospective case-series review of patients treated with an institution-approved warfarin reversal protocol. Patients with intracranial hemorrhage and known warfarin use with an international normalized ratio (INR)>1.4 received fresh frozen plasma (FFP), vitamin K (phytonadione), and weight-based, 3-factor PCC (Profilnine® SD) dose based on the initial INR. Demographic and clinical information, the degree of and time to INR normalization, and adverse events were recorded.The thirty study patients included 19 with primary ICH, 7 with SDH, and 4 with SAH. The mean age was 72.8 (±11) years, including 11 (37%) patients ≥80years old. The median presenting INR was 2.3 (IQR 2–3.3) and post-treatment INR was 1.4 (IQR 1.3–1.5, Z score 6.4, p<0.001). Median time from PCC administration to the first follow up INR was 95 (IQR 50–140) min. No patient's INR increased by more than 0.3 over 72h. Nine patients (30%) underwent neurosurgical procedures after PCC administration and no procedure-related bleeding complication was noted. Adverse events included 3 instances of early hematoma expansion, one ischemic stroke in a patient with endocarditis on post-PCC day 1, one pulmonary embolism 5weeks after PCC treatment, and one coronary in-stent thrombosis 60days after PCC treatment. 6 patients died prior to hospital discharge of anticipated complications of their initial event, and none from identifiable thrombotic complications of PCC.A 3-factor PCC preparation (Profilnine® SD), administered with FFP and vitamin K to patients with acute warfarin-associated intracranial bleeding is a reasonable approach to urgent warfarin reversal. However, randomized, prospective trials are needed to verify the safety and clinical effectiveness of PCC administration in this population.