Failure Of Medical Management Research Articles

Effect of Uterine Cavity Sonographic Measurements on Medical Management Failure in Women With Early Pregnancy Loss.

Medical management is commonly used among women with early pregnancy failure. The purpose of our study was to evaluate uterine content sonographic measurements for predicting medical management failure in early pregnancy loss. We conducted a retrospective cohort study in a university-affiliated hospital center including all women discharged from the emergency department (ED) with a diagnosis of early pregnancy failure who had medical management with misoprostol between 2011 and 2013. Only women with sonograms available for review were included in our study. All images were reviewed and the following cavity measurements, excluding the endometrial lining, were measured: cavity anteroposterior distance, cavity longitudinal distance, cavity transverse distance, and cavity volume. Logistic regression analysis was used to identify measurements that were independently associated with a subsequent need for dilation and curettage (D&C) and an unplanned return to the ED. Among 823 women presenting to the ED with first-trimester bleeding, 227 met inclusion criteria. Of all measurements evaluated, the cavity anteroposterior distance was found to be independently associated with D&C and an unplanned return to the ED. When a cavity anteroposterior distance cutoff of 15 mm was used, women were more likely to require D&C (adjusted odds ratio, 2.65; 95% confidence interval, 1.31-5.36; P< .01) and to have an unplanned return to the ED (adjusted odds ratio, 2.59; 95% confidence interval, 1.41-4.79; P < .01). In women with a cavity anteroposterior distance of less than 15 mm, 87.1% had successful medical management of early pregnancy loss, and 80.0% did not require an unplanned return to the ED. Although there is a need for further validation, patients identified as having a cavity anteroposterior distance of less than 15 mm should be considered good candidates for successful medical management.

Cervical Ectopic Pregnancy: A Clinician's Dilemma.

Stepwise approach to a rare case of cervical ectopic to preserve the fertility of a child-bearing woman in case of failed medical management but successful conservative approach is discussed below. Ectopic pregnancy, i.e. implantation of the blastocyst outside the endometrium of the uterine cavity, occurs in 1.9 % of reported pregnancies [1]. Cervical ectopic pregnancy is the rarest form of ectopic pregnancy. Its incidence varies from 1/1000 to 1/50,000 [2].

Radiofrequency Neurolysis for Lumbar Pain Using a Variation of the Original Technique

Background: Zygapophysial joint arthrosis is a pathology related with axial lumbar pain. The most accepted treatment, after failure of medical management, is the thermal denervation of the medial branch. Nonetheless, the placement of the heat probe remains a challenge to surgeons, even when using the fluoroscope. Using a variation of Shealy’s and Bogduk’s original techniques, which includes ablation of the medial branch and the nerves present in the joint capsule, we hypothesize that we can obtain similar outcomes to those found in the literature. Objective: To present the results attained over the last 8 years in the treatment of axial lumbar pain from zygapophysial joints degeneration, by employing a variation of the lumbar medial branch neurotomy technique, called 360-degree facet rhizotomy with radiofrequency. Study Design: Retrospective evaluation. Setting: Spine Center – Minimally Invasive Surgery in Bogotá, Colombia. Methods: A medical chart review was conducted for patients diagnosed with axial lumbar pain from zygapophysial joint arthrosis and treated with 360-degree facet rhizolysis with a high frequency radiofrequency energy source between 2008 and 2014. Data were evaluated under modified MacNab and pre- and postoperative visual analog scale (VAS) criteria. Results: We obtained a total of 73 patients. The average population age was 58.6 years. The preoperative VAS obtained was 7.3, which changed to 1.7 one year after the procedure. The MacNab criteria 12 months after the surgery gave satisfactory outcomes (excellent and good) from 91.7% of the patients. Limitations: This retrospective study includes inherent limitations and only offers one year follow-up data. Conclusions: Thermal therapy for zygapophysial joint arthrosis constitutes a safe and effective technique. The one year follow-up data presented here show that the ablation of the medial branch and nerves present in the joint capsule leads to satisfactory results in a high percentage of patients. Key words: Zygapophysial joint, lumbar axial pain, high frequency radiofrequency, facet arthrosis, neurolysis, thermal therapy, facet joint thermocoagulation

Abstract TP119: Angiogenic Factor Profiling in Medical Treatment of Intracranial Atherosclerosis (ICAS)

Objective: The purpose of this study was to identify circulating angiogenic factor profiles associated to success or failure of intensive medical treatment in ICAS patients. Methods: Prospective observational study of circulating angiogenic factors in 72 patients with ICAS treated medically. Twenty-one pro and antiangiogenic factors were isolated from plasma in patients with intracranial arterial stenosis greater than 70% due to ICAS. Patients were followed for 6 months and mRS were collected. Failure to medical management was defined as presence of TIA or stroke within 30 days of presentation. Levels of angiogenic factors were determined by plasma multiplex sandwich ELISA. Samples were run in duplicate with variation coefficient lower than 20%. Angiogenic profiles (APs) were defined using Principal Component Analysis (PCA). Seven profiles were selected (Eigenvalue greater than 1.0). A logistic regression model was built for the outcome variable medical management failure/success using the 7 APs as predictors. An ordinal logistic regression model was built to predict the outcome variable mRS at 6 months using age, gender, baseline mRS and APs as predictors. Results: Seventy-two patients with ICAS were included. Mean age was 61.8 (SD 12.3)yrs. There were 53% females. The predominant region of stenosis was the MCA. Of the 7 APs defined by PCA, the regression model identified AP-4 as significantly associated to failure of medical management (P=0.02). AP-4 was characterized by high levels of HGF and the anti-angiogenic factors VEGFR1, Endostatin, Angiostatin, VEGFR3, and TSP2. In the long-term follow up, AP-4 was positively associated with mRS, independently of baseline mRS and age (P=0.002). Conclusion: In this extensive prospective study of angiogenic factors in patients with ICAS, a profile characterized by elevation of HGF and several circulating anti-angiogenic factors was strongly associated with failure to medical management and poor outcomes at 6 months.

Pain and Functional Outcomes Following Vertebroplasty for Vertebral Compression Fractures

Introduction: There is a dearth of comparative outcome data on vertebroplasty for the treatment of vertebral compression fractures (VCF) according to vertebral level, number of levels, and etiology. The aim of this study was to investigate improvement of pain and function following vertebroplasty for a heterogenous cohort of patients with medically refractory VCF. Materials and Methods: A prospective observational study was conducted on a cohort of consecutive patients undergoing vertebroplasty following at least 4 weeks of failed medical management, between April 2007 and March 2012 at a single Neurosurgical center. Pain Visual Analogue Scale (VAS) scores, Oswestry Disability Index (ODI) scores, analgesic usage, and complications were recorded preoperatively and at 1 day, 1 week, 1 month, 6 months, and 1 year postoperatively. Intraoperative vertebral body biopsy was performed routinely. Results: 202 levels were augmented in 147 patients. The most common levels augmented were T12 (17%), L1 (18%), and L4 (10%). Significant reductions in pain VAS and ODI scores were evident at day 1 and sustained at up to 1 year postoperatively (P<0.001). They were not dependent on the level of fracture (T3-10, T11-L2, L3-S1) (P>0.05), number of levels treated (single level, 2 levels, >2 levels) (P>0.05), or etiology of VCF (P>0.05). At 1 year postoperatively, 79% (113/142) had no or reduced analgesic usage. The complication rate was 6% (9/147). There were 5 mortalities, none of which were directly related to surgery. Conclusions: Vertebroplasty for medically refractory VCF may offer sustained improvement in pain and function. The procedure is associated with low morbidity and mortality.

A study of the different treatment modalities used in the management of amoebic liver abscesses

Background: Amoebic liver abscess (ALA) is the most common extra intestinal manifestation of amoebiasis and is very common in the Indian subcontinent. ALA occurs in 3%-9% of patients with Entamoeba histolytica infection. Treatment modalities offered along with anti-amoebic medications are Guided percutaneous aspiration, Guided percutaneous drainage and Surgery. To study the indications and outcomes viz. symptomatic relief and resolution of clinical signs, resolution of the abscess, morbidity and mortality of the treatment modalities used for management of amoebic liver abscesses.Methods: This observational study included 100 patients diagnosed to harbour amoebic liver abscess. All the patients received metronidazole orally or intravenously in appropriate dose. Percutaneous aspiration (PCA) was used for impending rupture on ultasonography (rim &lt;10 mm), left lobe abscess, failure of medical management. Percutaneous catheter drainage (PCD) was performed for abscesses more than 150 cc, abscess with localised rupture and failure of medical management. Surgery was treatment offered in generalised peritonitis. Analysis pertaining to reduction of volume, duration of stay, morbidity and mortality was done for each modality.Results: Of the 100 patients, 33 were treated conservatively with medications alone with failure in 5 patients, 18 treated by percutaneous aspiration, 48 by percutaneous insertion of drain and 6 by surgery for ruptured abscess with generalised peritonitis. The mean duration of hospital stay in PCA group was 5.8 days while it was 9.12 days in PCD group. Bleeding (n=4) and bile leak (n=2) while bile leak (n=4) and death (n=2) were the complications reported in patients undergoing PCD and surgery, respectively.Conclusions: In Amoebic liver abscess PCA or PCD offers better and accelerated reduction in volume of abscess cavity with treatable morbidity and without fear of mortality and surgery can be avoided in these patients.

Total parathyroidectomy in patients with chronic kidney disease: Avoiding repeat surgery.

Renal hyperparathyroidism (RHPT) is a common complication of renal failure and it is associated with significant morbidity and mortality. The aim of this study was to determine the patient characteristics which might predict persistent or recurrent hyperparathyroidism after surgery and to assess the long-term effect of unsuccessful surgery. This is a retrospective study of all chronic kidney disease patients who required a total parathyroidectomy (TP) because of failed medical management from January 1999 to December 2014. Patient characteristics, preoperative imaging, operative findings, and patient outcome were all studied. Differences between groups (dialysis-dependent and nondialysis-dependent; preoperative imaging and no imaging) were tested by the Chi-square statistic test and P <0.05 was regarded statistically significant. Eighty-eight patients underwent TP during this period and were followed up for a median of 35.5 months (range 1-119 months). Seventy (80%) had removal of all parathyroid glands with associated fall in parathyroid hormone level. There were no statistically significant differences in surgical success rates in neither the dialysis-dependent versus nondialysis-dependent groups nor the preoperative imaging versus no imaging groups. Two patients underwent repeat parathyroid surgery for persistent hyperparathyroidism and 16 were followed up without surgery. Preoperative imaging did not direct surgical management nor reduce surgical failure rate in this series. The long-term effects of pharmaceutical developments in this area are unknown but are likely to change indications for initial parathyroidectomy and reoperation. An agreed protocol is essential for the management of patients with RHPT.

Clinical Analysis of Ectopic Pregnancies in a Tertiary Care Centre in Southern India: A Six-Year Retrospective Study.

Ectopic Pregnancy (EP) is a life-threatening emergency commonly encountered by medical practitioners where diagnosis can often be missed. Any woman in the reproductive age group, presenting with lower abdominal pain or vaginal bleeding must raise the suspicion of an ectopic pregnancy to prevent mortality and morbidity. To review all cases of EP and determine the incidence of EP. To study the high risk factors and know the types of clinical presentation, methods of diagnosis, outcome and complications. This was a retrospective cohort study, conducted at a tertiary care medical teaching hospital in Pondicherry, India. Medical records of all women with an EP between 2009 and 2015 were retrieved. Demographic data, parity, risk factors, clinical features, mode of management and need for blood transfusion was noted. Main outcome measures studied were the incidence of EP, risk factors, mortality and morbidity in these women. Data was entered in Microsoft Excel spreadsheet and analysed using SPSS software version 19.0. For categorical variables, data was compiled as frequency and percent. For continuous variables, data was calculated as mean ± SD. Seventy-two EP were diagnosed during the six-year period with an incidence of 9.1/1000 pregnancies. Majority of women were aged 21-30years (51.39%), 27.8% women were nulliparous. The most common risk factors were previous abortion (36.1%) and pelvic surgery (37.50%). Fifteen cases (20.8%) were diagnosed in women who had tubectomy. The classic triad of lower abdominal pain, amenorrhoea and vaginal bleeding was seen in 29(40.3%) cases. Ultrasonography was required to arrive at a diagnosis in 28(38.9%) cases. Urine pregnancy test was positive in 100% of cases. Majority (94.4%) were tubal ectopic pregnancies. Medical management with methotrexate alone benefitted 10(13.89%) of patients while another four required surgery for failed medical management. More than half of the patients (59.7%) required blood transfusion and two (2.8%) had transfusion related acute lung injury. No deaths were noted. Common risk factors for EP must be identified. Use of transvaginal ultrasonography and human chorionic gonadotropin assay have revolutionised the management of EP and serve as valuable adjuncts to early diagnosis and management.

Early Outcomes Following Endoluminal Deep Venous Reconstruction Using Dedicated Venous Stents

ObjectivesEvaluate early outcomes following endoluminal stenting using first-generation dedicated venous stents.MethodsPatients undergoing deep venous reconstruction using venous stents between 2012-2015 were identified. Duplex ultrasonography was used to assess sent patency at 1d, 2wks, 3mths, 6mths and yearly following intervention. Venous Disability Scores (VDS) and Villalta Scores (VS) taken before and after intervention (6wks, 6mths, yearly) were calculated.Results347stents were inserted in 140pts (median age 39yrs, 80 female) with median follow-up 16mths (1-38mths). Overall 1yr primary, primary-assisted and secondary patency rates were 67%, 80% and 82% respectively. The 1yr re-intervention rate was 30% with 16% occurring within two-weeks.57pts had stenting of residual stenoses after catheter-directed-thrombolysis for acute iliofemoral DVT. Median post-operative VDS and VS were 0 (P<0.001). 1pt developed an ulcer at 6mths.81pts had stenting for chronic outflow obstruction after failed medical management. 77pts (95%) had occluded vessels prior to treatment. The median pre-operative VS was 14 (4-23) and 9pts had an ulcer. Following intervention, the median VS was 4 (0-22, P<0.001) and ulcer healing was achieved in 67% (n=6/9).ConclusionsFirst-generation dedicated venous stents show promise at providing symptom relief in the short-term. Close surveillance is, however, required to maintain stent patency and factors that influence occlusion warrant further investigation. Long-term evaluation of these stents is required to investigate whether these encouraging early results can be maintained. DisclosuresSaha:Bayer: Honoraria. Black:Veniti: Consultancy. Cohen:Bayer: Consultancy, Honoraria, Research Funding, Speakers Bureau; Boehringer Ingelheim: Consultancy, Honoraria, Research Funding, Speakers Bureau; Daiichi Sankyo: Consultancy, Honoraria, Research Funding, Speakers Bureau; GSK: Consultancy, Honoraria, Research Funding; Merck: Consultancy, Honoraria, Research Funding; Johnson and Johnson: Consultancy, Honoraria, Research Funding; Mitsubishi Pharma: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Sanofi: Consultancy, Honoraria, Research Funding. Karunanithy:Cook: Honoraria.

Pain and functional outcomes following vertebroplasty for vertebral compression fractures – A tertiary centre experience

Objectives: There is a dearth of comparative outcome data on vertebroplasty for the treatment of vertebral compression fractures (VCF) according to vertebral level, the number of levels and aetiology. The aim of this study was to investigate the improvement of pain and function following vertebroplasty for a heterogeneous cohort of patients with medically refractory VCF. Methods: A prospective observational study was conducted on a cohort of consecutive patients undergoing vertebroplasty following at least 4 weeks of failed medical management, between April 2007 and March 2012 at a single neurosurgical centre. Pain visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) scores, analgesic usage and complications were recorded preoperatively and at day 1, week 1, 1 month, 6 months and 1 year postoperatively. Intraoperative vertebral body biopsy was performed routinely. Results: Two hundred and two levels were augmented in 147 patients. The most common levels augmented were T12 (17%), L1 (18%) and L4 (10%). Significant reductions in pain VAS and ODI scores were evident at day 1 and sustained at up to 1 year postoperatively (p < 0.001). They were not dependent on the level of fracture (T3-10, T11-L2 and L3-S1) (p > 0.05), the number of levels treated (single level, two-level and > two level) (p > 0.05) or aetiology of VCF (p > 0.05). At 1 year postoperatively, 79% (113/142) had no or reduced analgesic usage. The complication rate was 6% (9/147). There were five mortalities, none of which was directly related to surgery. Conclusion: Vertebroplasty for medically refractory VCF may offer sustained improvement in pain and function. The procedure is associated with low morbidity and mortality.

Vesical calculi in children

Vesical calculi occur due to increased urinary concentration & are commonly seen in children belonging to low socio-economic status. They are usually formed of ammonium acid urate, calcium oxalate or calcium phosphate. Vesical calculi constitute about 70% to 85% of paediatric urolithiasis & boys are affected more than girls. Primary vesical calculi occur in sterile urine & are associated with nutritional deficiency whereas Secondary calculi occur due to infection, obstruction or inflammation. Endemic calculi are associated with oxalate-rich diet. They usually present with hematuria, dysuria, frequent urinary tract infection, urinary urgency & bedwetting. The diagnostic modalities of vesical calculi are Urinalysis, urine dipstick test, serum Creatinine level, plain x-ray abdomen &Intravenous Pyelography. Sonogram is effective in identifying both radiolucent & radiopaque stones. Spiral CT scanning is highly sensitive & specific whereas Pelvic MRI orTechnetium-99m MAG-3 renal scanning yields poor resolution & are not recommended in the evaluation of bladder calculi. Treatment for vesical calculi depends on the size, composition & symptoms. The only effective medical treatment is urinary alkalization. Indications for surgery are failure of medical management, recurrent infections, acute urinary retention, suprapubic pain & significant gross hematuria. Open cystolithotomy was done earlier which is being replaced by cystolitholapaxy. With ongoing advances in instrumentation procedures like Transurethral optical litholapaxy are now applicable to children. Minimally invasive surgeries like extracorporeal lithotripsy, percutaneous nephrolithotripsy & urethroscopy have reduced open surgery to only 1- 4% of cases. Early diagnosis & appropriate management are essential for managing vesical calculi in children.

Effect of Menstrual Age on Failure of Medical Management in Women With Early Pregnancy Loss.

Women with failure of an early pregnancy and a gestational age of <8 weeks are considered good candidates for medical management. The purpose of our study was to evaluate the effect of menstrual age on the outcome of medical management in women with loss of a pregnancy at an estimated gestational age<8 weeks by ultrasound (US). We conducted a retrospective cohort study of all women discharged from the emergency department (ED) between 2011 and 2013 with a diagnosis of early pregnancy failure who were managed with misoprostol and who had a gestational age of <8 weeks on US. We used logistic regression to estimate the effect of menstrual age on failed medical management, defined as requiring dilatation and curettage (D and C) or having an unplanned return to the ED (URED). Among 823 pregnant women presenting to the ED with first trimester bleeding, 199 had pregnancy failure at <8 weeks by US and were discharged to use misoprostol. Increasing menstrual age was associated with an increased risk of D and C and URED. Specifically, the risk of D and C was 11.8% at <8 weeks, 18.5% at 8 to 9 weeks, 25.3% at 10 to 11 weeks, and 30.6% at ≥12 weeks (P<0.05). The risk of URED was 14.7% at <8 weeks, 27.8% at 8 to 9 weeks, 36.0% at 10 to 11 weeks, and 41.7% at ≥12 weeks (P<0.05). Increasing gestational age according to menstrual dates is associated with an increased rate of failed medical management in women with early pregnancy loss, independent of gestational age estimated by ultrasound. Gestational age by menstrual dates should be considered when discussing treatment options with women who have an early pregnancy failure.

The Role of Osmotic Therapy in Hemispheric Stroke.

Decompressive hemicraniectomy (DHC) can be lifesaving in hemispheric stroke complicated by cerebral edema. Conversely, osmotic agents have not been shown to improve survival, despite their widespread use. It is unknown whether medical measures can similarly confer survival in certain patient subgroups. We hypothesized that osmotic therapy (OT) without DHC may be associated with a greater likelihood of survival in particular populations depending on demographic, radiologic, or treatment characteristics. We performed a retrospective cohort analysis of patients with large anterior circulation strokes with an NIH stroke scale (NIHSS) ≥10 who received OT. We compared clinical, radiologic, and treatment characteristics between two groups: (1) those who survived until discharge with only OT (medical management success) and (2) those who required either DHC or died (medical management failure). Thirty patients met eligibility criteria. Median NIHSS was 19 [interquartile range (IQR) 13-24], and median GCS was 10 [IQR 8-14]. Forty-seven percent of the medical management cohort survived to discharge. Demographic characteristics associated with medical management success included NIHSS (p = 0.009) and non-black race (p = 0.003). Of the various interventions, the administration of OT after 24 hours and a smaller hypertonic saline dose was also associated with survival to discharge (p = 0.038 and 0.031 respectively). Our results suggest that patients with moderate size hemispheric infarcts on presentation and those who do not require OT within the first 24 h of stroke may survive until discharge with medical management alone. Black race was also associated with conservative management failure, a finding that may reflect a cultural preference toward aggressive management. Further prospective studies are needed to better establish the utility of medical management of hemispheric edema in the setting of moderate size hemispheric infarcts.

Systematic Review: Sequential Rescue Therapy in Severe Ulcerative Colitis: Do the Benefits Outweigh the Risks?

The options for medical management of acute severe steroid-refractory ulcerative colitis (UC) are limited. Recent guidelines recommend against use of sequential rescue therapy in the setting of failed medical management with initial salvage therapy. A systematic review was conducted to assess outcomes of sequential rescue therapy with infliximab (IFX) and calcineurin inhibitors like cyclosporine (CsA) or tacrolimus (Tac) in patients with steroid-refractory UC. A literature search identified studies that investigated treatment with IFX and CsA or Tac in acute severe UC. Outcomes of interest included short-term symptomatic response to treatment, rates of remission, adverse drug reactions, serious infections, mortality, and colectomy at 3 and 12 months. Overall, ten studies with 314 participants were eligible for inclusion. After sequential treatment, patients achieved short-term treatment response in 62.4% (95% confidence interval [CI], 57.0%-67.8%) of cases and remission in 38.9% (95% CI, 33.5%-44.3%). Colectomy rates were 28.3% (95% CI, 21.7%-34.5%) at 3 months and 42.3% (95% CI, 36.0%-48.6%) at 12 months. Adverse events were encountered by 23.0% (95% CI, 17.7%-28.3%) of patients, including serious infections in 6.7% (95% CI, 3.6%-9.8%) and mortality in 1% (95% CI, 0%-2.1%). The risk of sequential therapy in steroid-refractory UC seems lower than initially reported. Caution must be exercised however because of very low-quality evidence. In contrast to recent guidelines, the current analysis does not support a decision for or against use of sequential rescue therapy, which should only be performed at specialized referral centers familiar with the use of calcineurin inhibition.

Effect of Menstrual Age on Medical Management Failure in Women With Early Pregnancy Loss [295

INTRODUCTION: Women with gestational age less than 8 weeks are considered good candidates for medical management of early pregnancy failure. The purpose of our study was to evaluate the effect of menstrual age on failed medical management among women with early pregnancy failure estimated at less than 8 weeks of gestation by ultrasonography. METHODS: We conducted a retrospective cohort study on all women discharged from the emergency department with a diagnosis of early pregnancy failure who were managed with misoprostol and had a gestational age less than 8 weeks on ultrasonography between 2011 and 2013. We used logistic regression to estimate the effect of menstrual age on failed medical management defined as dilatation and curettage (D&C) or unplanned return to the emergency department. RESULTS: Among 823 women presenting to the emergency department with first-trimester bleeding, 199 had failed pregnancy less than 8 weeks of gestation by ultrasonography and were discharged with misoprostol. Menstrual age was associated with an increased risk of D&C and unplanned return to the emergency department. Specifically, risk of D&C was 11.8% at less than 8 weeks of gestation, 18.5% at 8–9 weeks of gestation, 25.3% at 10–11 weeks of gestation, and 30.6% at 12 weeks of gestation or greater (P=.04). As well, risk of unplanned return to the emergency department was 14.7% at less than 8 weeks of gestation, 27.8% at 8–9 weeks of gestation, 36.0% at 10–11 weeks of gestation, and 41.7% at 12 weeks of gestation or greater (P=.01). CONCLUSION: Menstrual gestational age is an important predictor of failed medical management of early pregnancy loss that is independent of ultrasound-estimated gestational age. Menstrual gestational age should be considered when discussing treatment options with women who have an early pregnancy failure.

Effect of Uterine Cavity Measurements on Medical Management Failure in Early Pregnancy Loss [296

Effect of Uterine Cavity Measurements on Medical Management Failure in Early Pregnancy Loss [296

(582) - Subclinical Hemorrhagic Cerebral Lesions Are Prevalent in Patients With Long Term Continuous-Flow LVAD Support

s S217 de Chile, Santiago, Chile; 3Unidad de Trasplante, Instituto Nacional del Torax, Santiago, Chile. Purpose: Bridge-to-transplant long-term devices are commonly not affordable for our health system and usually they are not suitable for critically ill patients. Centrimag® may be an alternative for a one-step bridge-to-transplant surgical procedure. Methods: Retrospective review of 28 patients subjected to Centrimag® implantation. Twenty-three (82%) were male, mean age 42+13 years. Etiology of heart failure was ischemic in 13(46%), dilated cardiomyopathy in 8(29%), and other 7(25%).All were INTERMACS class I, 27(96%) had multiorgan failure, and in 26(93%) the indication was failure of medical management. Twelve (43%) had previous cardiac arrest with a mean arrest time of 21+17 min. Circulatory support was biventricular: 25(89%), univentricular 3(11%), and in 9(32%) an oxygenator was interposed until respiratory recovery. Results: Thirty-day post-implant survival was 79% (22 patients). Bridge-totransplant or recovery: 20 (71%) patients. Mean support time was 40 days, and 12(43%) were supported > 4 weeks. The longest support was 292 days. Eight (29%) died before been bridged. Post-implant complications: re-exploration for bleeding 10(36%), neurologic dysfunction 4(14%), pneumonia 10(36%), bacteremia 5(36%) and acute dialysis 8(29%). Kaplan Meier two-year survival: 62+10%. Mean follow-up time: 21 months with a total of 579 months. All alive patients were in NYHA functional class I with normal biventricular function. Conclusion: Centrimag® is useful to provide medium-term support for cardiogenic shock in a developing country. Support longer than 4 weeks is feasible. A bridge-to-transplant long-term device may not be needed in the setting of a waiting time less than 3 months.

Pre-operative intraocular pressure does not influence outcome of trabeculectomy surgery: a retrospective cohort study.

BackgroundTo investigate whether pre-operative intraocular pressure (IOP) predicts outcome of trabeculectomy surgery in patients with primary open angle glaucoma over a 3-year period of follow-up.MethodsRetrospective cohort study, of a total of 61 patients (80 procedures) who had undergone trabeculectomy surgery after failed medical management at a single centre between 2000 and 2011. Patients were identified through surgical logbooks. A subsequent case note-review identified 61 patients (80 procedures) with primary open angle glaucoma (POAG). The primary outcome was success of trabeculectomy surgery, with failure defined as intraocular pressure (IOP) > 21 mmHg, ≤ 5 mmHg or not reduced by 20% at two consecutive follow-up visits 3-months post-operatively. Qualified success was defined as surgical success with the use of supplemental medical therapy. Secondary outcomes included visual acuity, Humphrey visual field MD, surgical complications and post-operative interventions.ResultsAt 3 years, the odds ratio of failure was 0.93 per mmHg pre-operative IOP (95% C.I. 0.83-1.03, p = 0.15 Wald Χ2 test), and the odds ratio of failure or qualified success was 0.96 (95% C.I. 0.89-1.04, p = 0.35). The incidence of surgical complications showed an odds ratio of 1.02 per mmHg pre-operative IOP (95% C.I. 0.95-1.10, p = 0.55 Wald Χ2 test). The incidence of post-operative interventions showed an odds ratio of 1.01 per mmHg pre-operative IOP (95% C.I. 0.94-1.09, p = 0.80 Wald Χ2 test).ConclusionsPre-operative IOP does not predict success of trabeculectomy surgery in POAG patients during the first 3 years of follow-up. The incidence of surgical complications and post-operative interventions shows no association with pre-operative IOP.

Abstract 135: Angiogenic Factors and Response to Intensive Medical Management in Atherosclerotic Intracranial Arterial Stenosis

Introduction: Intracranial atherosclerotic steno-occlusive disease (ICASD) is the most common cause of stroke worldwide accounting for 33-67% of stroke in countries with predominantly Asian, Hispanic, and Black populations and at least 10% of all strokes in the US. In this study we test the hypothesis that circulating angiogenic factor profiles are associated with response to medical management. Methods: This is a prospective cohort of participants in the Angiogenic Factors in Intracranial Arterial Stenosis (ANFIS) Study, age 30-80, with a diagnosis of 70-99% ICASD of a major intracranial artery. All patients had optimization of medical management. Failure of medical treatment was defined as presence of TIA or strokes within 30 days of enrollment. Angiogenic factors were isolated in peripheral blood: HBEGF, VEGF, VEGF-D, TGFB1, TGFB2, PDGFAA, PDGFBB, Endostatin, Angiostatin, and VEGFR2. A correlation matrix was used to group highly correlated factors. Multivariable logistic-regression models were prepared to estimate risk of medical management failure. Results: Thirty patients (53% female) age 28-86 (mean 62.5) were enrolled. There were 10 (33.3%) failures of medical management. Age, gender, ethnicity and race were not significantly different between responders and failures of medical treatment. The multivariate analysis showed that higher VEGFD levels were associated with reduced failure (OR=0.26 95%CI 0.06-0.63, p=0.02) and higher HBEGF was associated with increased failure (OR=2.52 95%CI 1.28-7.34, p=0.03). The multivariate logistic model including VEGFD, HBEGF, female sex and black race had 90% sensitivity and 75% specificity (AUC 0.87) in predicting failure of management. Conclusion: In patients with severe (&gt;70%) ICASD, elevated circulating HBEGF levels were associated with failure of medical treatment, while elevated circulating VEGFD levels were associated with protection from TIA/stroke. Further evaluation of the role of these factors in stroke prevention and potential collateral formation could elucidate new pathways for the treatment of intracranial atherosclerotic disease.

P-075 YI Systematic Review

The options for medical management of acute severe steroid-refractory ulcerative colitis (UC) are limited. Recent guidelines caution against use of sequential rescue therapy in the setting of failed medical management with an initial salvage therapy. A systematic review was conducted to assess the outcomes of sequential rescue therapy with infliximab (IFX) and calcineurin inhibitors like cyclosporine (CsA) or tacrolimus (Tac) in patients with steroid refractory UC. A literature search identified studies that investigated treatment with IFX and CsA or Tac in acute severe UC. The primary outcome was short term symptomatic response to treatment. Secondary outcomes included adverse drug reactions, serious infections, mortality, rates of remission, and colectomy at 3 months and 12 months. Response rates with 95% confidence intervals (CI) are reported. Overall, 10 studies with 314 participants were eligible for inclusion. After sequential treatment patients achieved short-term treatment response in 62.4% (95% CI, 57.0%–67.8%) of cases and remission in 38.9% (95% CI, 33.5%–44.3%). Colectomy was required in 28.3% (95% CI, 21.7%–34.5%) of patients at 3 months and 42.3% (95% CI 36.0–48.6) at 12 months. Adverse events were encountered by 23.0% (95% CI, 17.7%–28.3%) of patients, including serious infections in 6.7% (95% CI, 3.6%–9.8%) and mortality in 1% (95% CI, 0%–2.1%). Our data summarizing experience from observational studies suggest that the risk-benefit ratio of sequential rescue therapy in acute severe UC seems acceptable. In the setting of failure of corticosteroids and an initial rescue therapy for acute severe UC, consideration can be given to use of another salvage agent based on patient preferences and the safety of this experience from observational data. The sequence of IFX followed by calcineurin inhibitors, or vice versa, have similar treatment outcomes and adverse events. Precautions to minimize the risk of adverse events, including early assessment of treatment response, use of serum drug levels to guide initiation of therapy, and early weaning of concurrent corticosteroids is recommended.