Low-risk Procedure Research Articles

Fertiloscopy and its place in the gynaecologist's armamentarium.

Infertility is a prevalent issue worldwide. Current investigation of female pelvic infertility uses transabdominal laparoscopy, exposing patients to its associated risks. An alternative method is fertiloscopy, comprising hysteroscopy, tubal dye studies, and transvaginal hydrolaparoscopy (TVHL), falling under the broader category of VNOTES. This study reviews fertiloscopy cases in Australia to assess its role in managing infertility. Retrospective analysis of 76 cases was performed with review of imaging results, fertiloscopy findings and interventions, and fertility outcomes. Statistical analysis was conducted via R Studio v4.1 with means and averages used for descriptive data and a Kruskal-Wallis analysis of variance test used to evaluate differences in continuous variables. Kaplan-Meier curves were constructed to describe cumulative pregnancy incidence, with differences evaluated using log-rank tests. Statistical tests were two-tailed, and a P-value < 0.05 was considered significant. Of 76 cases, 70 underwent fertiloscopy and 35 an intra-operative intervention. Of the cohort, 53 conceived, 18 spontaneously. The highest chance of spontaneous conception was 44% by day 283. The failure rate of fertiloscopy was 5.3%, and complications occurred in 1.3% of cases. The highest chance of spontaneous conception post-fertiloscopy was 44% by day 283, possibly indicating the time between the procedure and referral to reproductive therapies. This study identified a low associated failure and complication rate, supporting fertiloscopy as a low-risk procedure. Despite limitations, this study highlights spontaneous pregnancy outcomes and associated low complication and failure rates, emphasising fertiloscopy's role in managing infertility in Australia as a lower risk surgical alternative to standard laparoscopy.

Abstract 4128201: Reducing Blood Product Waste in a Pediatric Cardiac Catheterization Laboratory – A Quality Improvement Initiative

Background/Aim: Transfusion can be a life-saving intervention, however routine pre-procedural blood products frequently go unused. Recent national blood product shortages highlight the importance of blood product stewardship. In our pediatric cardiac catheterization laboratory (PCCL), packed red blood cells (pRBCs) were ordered prior to all cases. These units are rarely transfused and sometimes cannot be reallocated, resulting in waste. As a quality improvement project, we set a primary aim to reduce the percentage of monthly pRBC waste from a baseline mean of 7.4% to &lt;5% over 12 months. Methods: Baseline data on all cardiac catheterization cases, excluding electrophysiology, lymphatic, and hybrid cases, were collected from 1/1/2022 to 2/28/2023. Interventions (Table 1) were implemented and outcomes measured from 3/1/2023 to 3/31/2024. Primary outcome measures were monthly percentage of blood wasted, and percent of unused pRBC orders. Emergency blood product activation was measured as a balancing metric. Statistical process control charts were used to display and analyze data. Results: During the intervention period 1,318 cases were performed of which 32% met low-risk criteria for pRBC order de-implementation. The percent of blood that was subsequently wasted was reduced from 7.4% to 5.5% (Figure 1A), primarily driven by the reduction in the anecdotal practice of pRBC unit splitting in patients &lt;1 year old (Figure 1B). The percent of unused pRBC orders was reduced from 97% to 79% with sustained improvement following two cycles of routine blood order de-implementation for low-risk cases. No emergency blood activation occurred (0%, 97.5% CI: 0-0.28%). Conclusion: De-implementation of default pRBC orders for low-risk catheterization procedures and reduction in unit splitting reduced the percent of blood wasted in our PCCL, saving time and cost without compromising patient safety. A data-driven approach to blood stewardship may be broadly applicable across procedural areas.

Dual Chamber Pacemaker Implant in Coronary Sinus Leading to Several Complications

Permanent pacemaker implantation is a low-risk procedure. However, complications may occur at a rate of around 4–8%. We present a case where initial implantation resulted in complications that could have been avoided by meticulous assessment of lead position in different projections and early post-procedure X-ray that would have delineated other serious complications. We present a case where the right ventricular lead was placed in the coronary sinus, which resulted in the loss of pacing capture with further syncope after the pacemaker implant. This was apparent in the post-procedure electrocardiogram (ECG) with right bundle branch pacing and the lead was repositioned in the right ventricular apex the following day. Furthermore, the patient was discharged home without a chest X-ray (CXR), and she represented a week later with a haemo-pneumothorax and pericardial effusion. A chest drain was placed and was discharged after a slow recovery following several complications that could have been avoidable.

Using Quality Improvement to Optimize Blood Product Utilization in a Pediatric Cardiac Catheterization Laboratory.

Packed red blood cells (PRBC) are frequently ordered for cardiac catheterization procedures, which increases resource utilization and patient charges. We applied the Plan-Do-Study-Act (PDSA) principle in order to optimize the ordering of PRBC for pediatric cardiac procedures and reducing charges. Our primary aim was to increase adherence to ordering guidelines to greater than 97%, with a global aim to reduce resource utilization. The existing PRBC ordering guidelines were revised and procedure reports were updated to include administration of PRBC. The rate of pre-procedure PRBC orders, adherence to the new protocol guidelines, presence of documentation and rate of blood transfusion within 24h post-procedure, frequency of emergency release blood during a procedure were monitored. During our study period, there was an increased adherence from 86 to 100% adherence following implementation of the updated guidelines. With improved adherence, we decreased PRBC ordering and hospital charges to the patient in low-risk cardiac catheterization procedures, without an increase in blood transfusions.

Risk-Specific Training Cohorts to Address Class Imbalance in Surgical Risk Prediction.

Machine learning tools are increasingly deployed for risk prediction and clinical decision support in surgery. Class imbalance adversely impacts predictive performance, especially for low-incidence complications. To evaluate risk-prediction model performance when trained on risk-specific cohorts. This cross-sectional study performed from February 2024 to July 2024 deployed a deep learning model, which generated risk scores for common postoperative complications. A total of 109 445 inpatient operations performed at 2 University of Florida Health hospitals from June 1, 2014, to May 5, 2021 were examined. The model was trained de novo on separate cohorts for high-risk, medium-risk, and low-risk Common Procedure Terminology codes defined empirically by incidence of 5 postoperative complications: (1) in-hospital mortality; (2) prolonged intensive care unit (ICU) stay (≥48 hours); (3) prolonged mechanical ventilation (≥48 hours); (4) sepsis; and (5) acute kidney injury (AKI). Low-risk and high-risk cutoffs for complications were defined by the lower-third and upper-third prevalence in the dataset, except for mortality, cutoffs for which were set at 1% or less and greater than 3%, respectively. Model performance metrics were assessed for each risk-specific cohort alongside the baseline model. Metrics included area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve (AUPRC), F1 scores, and accuracy for each model. A total of 109 445 inpatient operations were examined among patients treated at 2 University of Florida Health hospitals in Gainesville (77 921 procedures [71.2%]) and Jacksonville (31 524 procedures [28.8%]). Median (IQR) patient age was 58 (43-68) years, and median (IQR) Charlson Comorbidity Index score was 2 (0-4). Among 109 445 operations, 55 646 patients were male (50.8%), and 66 495 patients (60.8%) underwent a nonemergent, inpatient operation. Training on the high-risk cohort had variable impact on AUROC, but significantly improved AUPRC (as assessed by nonoverlapping 95% confidence intervals) for predicting mortality (0.53; 95% CI, 0.43-0.64), AKI (0.61; 95% CI, 0.58-0.65), and prolonged ICU stay (0.91; 95% CI, 0.89-0.92). It also significantly improved F1 score for mortality (0.42; 95% CI, 0.36-0.49), prolonged mechanical ventilation (0.55; 95% CI, 0.52-0.58), sepsis (0.46; 95% CI, 0.43-0.49), and AKI (0.57; 95% CI, 0.54-0.59). After controlling for baseline model performance on high-risk cohorts, AUPRC increased significantly for in-hospital mortality only (0.53; 95% CI, 0.42-0.65 vs 0.29; 95% CI, 0.21-0.40). In this cross-sectional study, by training separate models using a priori knowledge for procedure-specific risk classes, improved performance in standard evaluation metrics was observed, especially for low-prevalence complications like in-hospital mortality. Used cautiously, this approach may represent an optimal training strategy for surgical risk-prediction models.

POST-MASTECTOMY SURGICAL SITE INFECTION RATES IN FEMALES WITH BREAST CARCINOMA IN PREMENOPAUSAL AGE: A SINGLE CENTER STUDY

Breast surgery, like mastectomy, is generally considered a low-risk procedure for surgical site infections (SSIs), but when SSIs do occur, they can lead to significant complications. Identifying risk factors to improve patient outcomes and minimize complications is essential. Objective: This study aimed to determine the frequency of post-mastectomy surgical site infections (SSI) in premenopausal females with breast carcinoma and to identify the associated risk factors. Methods: This descriptive case study included 100 premenopausal females diagnosed with breast carcinoma who underwent mastectomy at a tertiary care hospital, Shaikh Zayed Hospital Lahore, from April 2024 to August 2024. The age range of participants was 25-45 years, with a mean age of 39 ± 5.3 years. Demographic data, including age, gender, body mass index (BMI), comorbidities, and American Society of Anesthesiologists (ASA) score, were collected. Intraoperative variables such as blood loss (mean: 350 ± 50 ml) and surgery duration (mean: 120 ± 15 minutes) were also recorded. All patients received standard postoperative antibiotic prophylaxis, including cefazolin or clindamycin, for those allergic to penicillin. The surgical site was assessed 30 days postoperatively for signs of infection, including erythema, pus discharge, or fever exceeding 38°C. SSIs were categorized based on the Centers for Disease Control and Prevention (CDC) guidelines into superficial, deep, and organ/space infections. Results: The overall infection rate was 7.5% (n=7). Of these, 4 cases were superficial infections, while 3 involved deeper tissue layers, requiring drainage and further antibiotics. Factors significantly associated with an increased risk of disease in the multivariate logistic regression model included a high wound class (contaminated or dirty; OR: 3.2, p=0.01), elevated ASA score (ASA III-IV; OR: 2.8, p=0.03), high BMI &gt;30 (OR: 3.5, p=0.002), diabetes (OR: 4.1, p=0.001), use of surgical drains (OR: 2.9, p=0.02), and reoperation (OR: 4.3, p=0.005). The mean hospital stay was extended by 4.5 days (from 5.2 ± 1.5 days in non-infected patients to 9.7 ± 3.1 days in infected cases). Conclusion: The study found a post-mastectomy surgical site infection rate of 7.5% in premenopausal females, with significant risk factors including high BMI, diabetes, use of surgical drains, and the need for reoperation. A high wound class and elevated ASA score also predicted increased infection risk. Addressing these modifiable risk factors through optimized perioperative care, such as better glycemic control, judicious use of surgical drains, and minimizing reoperations, may help reduce SSI rates and improve outcomes for breast cancer patients.

The Analysis Study of Risk of Bleeding in Patients Undergoing Pulmonary Procedure on Antiplatelet or Anticoagulant: A Comprehensive Systematic Review

Background: Pumonary procedure is considered to be a low bleeding risk procedure, platelet count and coagulation profile are usually evaluated prior to the procedure. In addition, several society guidelines recommend holding antiplatelet medications such as clopidogrel and prasugrel for 5 days prior to the procedure as well as holding one dose of unfractionated heparin prior to pulmonary procedure. The aim: The aim of this study to show about risk of bleeding in patients undergoing pulmonary procedure on antiplatelet or anticoagulant. Methods: By the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. Result: Eight publications were found to be directly related to our ongoing systematic examination after a rigorous three-level screening approach. Subsequently, a comprehensive analysis of the complete text was conducted, and additional scrutiny was given to these articles. Conclusion: Pulmonary procedure on patients receiving either antiplatelet or anticoagulation therapy using the best available evidence. With this knowledge, physicians can assist patients or their substitute decision-makers in making an informed decision regarding the timing and safety of proceeding with a pulmonary procedure.

Sterile gown and drape, and bouffant cap for thyroid FNA: preventing infections or producing unnecessary medical waste?

Ultrasound-guided fine needle aspiration (FNA) is a very low-risk procedure. Despite this, there remains great variability in the use of protective equipment. Given the monetary and environmental costs of protective equipment, the difference in infection rates with full versus limited protective equipment was assessed. A total of 857 consecutive patients were retrospectively reviewed after undergoing thyroid FNAs at the main hospital and outpatient clinic siteperformed from 12/1/2020 to 11/30/2023. The hospital site operated with full protective equipment (bouffant, sterile gown, sterile gloves, and full body sterile drape), and the outpatient site with limited (sterile gloves, limited sterile paper drape) protective equipment. Two patients were excluded as no procedure was performed. Review for signs of infection within 30days of procedure was performed using medical records, which was blinded to the extent of protective equipment utilization. No infections were identified in either group, with 0/629 (0%, 95%CI 0-1%) in the full protective equipment group vs. 0/226 (0%, 95%CI 0-2%) in the limited protective equipment group. There was no statistically significant difference in infection rate between full and limited protective equipment use in thyroid FNA in the included 855 procedures (95%CI 0-1%). Two patients out of 629 (0.3%) in the full protective equipment group developed mild allergic reaction to topical antiseptic. The 226 procedures with limited protective equipment represent a saving of at least 204,530g of CO2 equivalents, equivalent to driving a car for almost 3000 miles. Reducing the extent of protective equipment does not adversely affect the infection rate in thyroid FNAs. Given the inherent costs involved in the procurement and waste of protective equipment, reducing protective equipment use is warranted to reduce both the monetary and environmental impacts of waste.

Static reanimation of the paralyzed face using non-absorbable polypropylene mesh.

&lt;br&gt;&lt;b&gt;Introduction:&lt;/b&gt; There are 2 methods for correcting facial deformities resulting from facial nerve paralysis - dynamic and static. Although dynamic methods are the standard approach in selected patient groups, static facial suspension using synthetic material provides a minimally invasive alternative for those who do not qualify for them.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Aim:&lt;b&gt; Presenting experiences with the use of non-absorbable polypropylene mesh in the Department of Plastic Surgery in Polanica-Zdrój and reviewing the literature related to static facial reanimation methods.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Materials and methods:&lt;/b&gt; Fourteen patients underwent static facial tissue suspension using non-absorbable polypropylene mesh and 12 patients underwent surgery using classical autologous tissue techniques between 2019 and 2023. Indications for surgical treatment were analyzed, and preliminary results of treatment using both methods were compared.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; Compared to autologous tissue methods, surgeries using synthetic mesh were associated with shorter hospitalization times. No long-term postoperative complications were observed in any patient. There were no differences in treatment outcomes between autologous tissue and synthetic mesh techniques, and all patients assessed the outcome as favorable.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Discussion:&lt;/b&gt; Treatment of facial nerve paralysis sequelae using static techniques should be considered for patients not qualifying for surgery with dynamic methods and/or not consenting to such procedures. Using synthetic material as an alternative to autologous material reduces surgical time and avoids donor-site injuries and prolonged recovery.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; Facial suspension with synthetic material is an effective, low-risk procedure for static correction of facial nerve paralysis sequelae.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Study significance:&lt;/b&gt; Emphasizing the importance of static methods in facial reanimation.&lt;/br&gt.

Impact of Procedure Risk vs Frailty on Outcomes of Elderly Patients Undergoing Emergency General Surgery: Results of a National Analysis.

The direct association between procedure risk and outcomes in elderly patients who undergo emergency general surgery (EGS) has not been analyzed. Studies only highlight the importance of frailty. A comprehensive analysis of relevant risk factors and their association with outcomes in elderly patients who undergo EGS is lacking. We hypothesized that procedure risk has a stronger association with relevant outcomes in elderly patients who undergo EGS compared with frailty. Elderly patients (age >65 years) undergoing EGS operative procedures were identified in the NSQIP database (2018 to 2020) and stratified based on the presence of frailty calculated by the Modified 5-Item Frailty Index (mFI-5; mFI 0 nonfrail, mFI 1 to 2 frail, and mFI ≥3 severely frail) and based on procedure risk. Multivariable regression models and receiving operative curve analysis were used to determine risk factors associated with outcomes. A total of 59,633 elderly patients who underwent EGS were classified into nonfrail (17,496; 29.3%), frail (39,588; 66.4%), and severely frail (2,549; 4.3%). There were 25,157 patients in the low-risk procedure group and 34,476 in the high-risk group. Frailty and procedure risk were associated with increased mortality, complications, failure to rescue, and readmissions. Differences in outcomes were greater when patients were stratified according to procedure risk compared with frailty stratification alone. Procedure risk had a stronger association with relevant outcomes in elderly patients who underwent EGS compared with frailty. Assessing frailty in the population of elderly patients who undergo EGS without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes.

Management of Primary Immune Thrombocytopenia: Turkish Modified Delphi-Based Consensus Statement for Special Considerations

Primary immune thrombocytopenia (ITP) is an acquired disorder of platelets with a complex and unclear mechanism of increased immune destruction or impaired production of platelets. While the management of ITP is evolving, there is still a need for guidance, particularly in certain circumstances such as pregnancy, emergencies, or patients requiring co-medications. We aimed to determine the tendencies of hematologists in Türkiye in the event of such special considerations. Applying a modified Delphi method, the Turkish National ITP Working Group, founded under the auspices of the Turkish Society of Hematology, developed a questionnaire consisting of statements regarding pregnancy, emergencies, and circumstances requiring co-treatment with antiaggregants or anticoagulants. A total of 107 hematologists working in university or state hospitals voted for their agreement or disagreement with the statements for two sequential rounds. The participating hematologists reached an agreement on starting treatment for pregnant patients with platelets of less than 30x109/L and delivery either vaginally or by cesarean section being safe at platelet counts above 50x109/L. For emergencies and the rescue management of ITP, the panel agreed against the use of high-dose corticosteroids alone, preferring combinations with transfusions or intravenous immunoglobulin. For patients who require interventions, platelet counts of >50x109/L were regarded as safe for low-risk procedures as well as co-treatment with antiplatelets or anticoagulants. As the National ITP Study Group, we have observed the need to increase the practice guidance regarding patients with primary ITP requiring additional treatments including invasive interventions and co-treatments for coagulation. Decisions on the management of ITP during pregnancy should be individualized. There is a lack of consensus on the thresholds of platelet counts as well as co-morbidities and co-medications. This lack of consensus may be due to variations in practices.

A multicenter study of the risk of major bleeding in patients with and without cirrhosis undergoing percutaneous liver procedures.

Percutaneous liver procedures are frequently performed in patients with abnormal coagulation tests. Current guidelines suggest prophylactic transfusion is not mandatory in all patients with liver disease or cirrhosis, depending on the risk of bleeding. This study aims to describe the incidence and risk of major bleeding after percutaneous liver procedure in patients with and without cirrhosis. This retrospective study includes patients who underwent percutaneous liver biopsy and radiofrequency and microwave ablation of liver lesions at 3 centers in Spain. A transfusion protocol was considered for platelet counts <50,000 and/or international normalized ratio >1.5. The primary outcome was major bleeding. A total of 1797 patients were included in the study, with 316 having cirrhosis (18%) and 1481 without cirrhosis (82%). Among the patients with cirrhosis, 80 were classified as Child A, and percutaneous liver biopsy was the most frequent procedure (86%). Fourteen patients (0.8%) experienced major bleeding, with 0.4% occurring in radiofrequency and microwave ablation and 0.8% in percutaneous liver biopsy. Bleeding occurred in 0.6% of patients with cirrhosis compared to 0.8% in those without ( p = ns). No clinical or procedural variables were associated with bleeding. Twenty-five patients (1.4%) had an international normalized ratio >1.5, and 22 patients (1.2%) had a platelet count <50,000. Only 24% (6/25) of patients with an international normalized ratio >1.5 were transfused with fresh frozen plasma, and 72% (16/22) of those with platelet counts <50,000 received platelet transfusion. Patients with cirrhosis were more frequently transfused (5.9% vs. 1.5%). None of the patients who met the criteria for transfusion experienced major bleeding, regardless of whether they received a transfusion, and none of the patients who had a major bleeding episode met the transfusion criteria. In this cohort, major bleeding after percutaneous liver procedure occurred in <1% of patients, making it a low-risk procedure for patients with and without cirrhosis. Although not uniformly adopted, the current transfusion protocol still led to unnecessary blood product administration.

Aerosol generation during pediatric otolaryngological procedures

ObjectivesTo assess the extent of staff exposure to aerosol generation in common pediatric otorhinolaryngological procedures (tonsillotomies, adenoidectomies, and tympanostomies) and determine the surgical phases responsible for most aerosol generation in these procedures. MethodsAerosol generation was measured during 35 pediatric otolaryngological procedures using an Optical Particle Sizer that measures aerosol concentrations for particle sizes between 0.3 and 10.0 μm. The different phases of and instruments used in each procedure were logged. Operating room background aerosol levels and coughing were used as references. ResultsTotal aerosol concentrations were significantly higher during tonsillotomies and adenoidectomies when compared to tympanostomies (p = 0.011 and p = 0.042) and to empty room background aerosol concentrations (p = 0.0057 and p < 0.001). Aerosol concentration during tonsillotomies did not differ from coughing, which is considered as standard for high-risk aerosol procedures. During tympanostomies, aerosol concentrations were even lower than during perioperative concentrations. No statistically significant difference in aerosol generation comparing suction, electrocautery, cold instruments, and paracentesis was found. ConclusionAccording to the results of this study, tympanostomies are low-risk aerosol-generating procedures. On the other hand, pediatric tonsillotomies produced aerosols comparable to coughing, pointing to them being significantly aerosol-producing procedures and viral transmission is theoretically possible intraoperatively.

Effect measure modification in an RCT of antibiotic prophylaxis in laparoscopic cholecystectomy: A secondary analysis

Background: Antimicrobial resistance is a growing public health threat. To alleviate selective pressure which leads to the emergence and proliferation of resistance, and to preserve the utility of treatments where they are needed the most, antimicrobial stewardship programs (ASPs) could consider revising surgical antibacterial prophylaxis protocols for low-risk procedures such as laparoscopic cholecystectomy. Methods: Publicly available data was used from a well-powered randomized controlled trial conducted by Matsui and colleagues during 2007-2013 in Japan on the effectiveness of prophylactic antibacterial treatment on reducing post-operative infections following laparoscopic cholecystectomy in low-risk patients. A total of 1037 patients were randomized to receive treatment or no treatment. After randomization, laparoscopic cholecystectomies were converted to open procedures in 28 patients, 14 in each arm, constituting a deviation from the protocol and the administration of additional antibacterial treatment. The original study included both intention-to-treat and per-protocol analyses, finding statistically significant reductions in post-operative infections in the treatment vs no treatment arm (1.2% vs 6.7%, p&lt;0.0001; 1.0% vs 5.9%, p&lt;0.0001, respectively). In the present analysis I assessed the extent to which type of procedure modified the effect of antibacterial prophylaxis on post-operative infection using both additive and multiplicative interaction. Risk and risk differences were estimated using a linear-binomial model and risk ratios were estimated using a log-binomial model. Alpha was set to 0.10. The lowest risk categories for each variable, being assigned to treatment and receiving a laparoscopic procedure, defined the common reference category. Results: A 35 percentage point (pp) increase in the risk of post-op infections relative to the reference category was attributable to the joint effects of omitting prophylaxis and conversion to an open procedure (90% CI 14, 56), compared to a 5 pp increase attributable to omission of prophylaxis (90% CI 3, 7) or a 6 pp increase attributable to conversion to an open procedure (90% CI -5, 18) by themselves. The interaction contrast capturedthis super-additive 24 pp increase in risk (90% CI -1, 47). The relative excess risk due to interaction was 23.81 (90% CI -5.56, 53.19), suggesting a departure from additivity as well. Conclusions: Patients undergoing open cholecystectomies stand to benefit the most from antibacterial prophylaxis compared to patients who have laparoscopic cholecystectomies. ASPs could consider reducing or eliminating surgical prophylaxis in low-risk procedures such as laparoscopic cholecystectomy to alleviate selection pressure for antibacterial resistant organisms and preserve its effectiveness for people undergoing higher risk procedures.

Management of edoxaban therapy in patients undergoing emergency/urgent procedures: a subanalysis of the global, prospective, observational, multinational EMIT-AF/VTE programme

Abstract Background Physicians are often unable to follow recommendations for preprocedural oral anticoagulant interruption before emergency/urgent (unplanned) procedures, which may lead to a higher incidence of adverse outcomes in these patients compared with those who undergo planned procedures. The Global EMIT-AF/VTE programme found low bleeding and thromboembolic event rates for patients receiving edoxaban who underwent diagnostic or therapeutic procedures. However, edoxaban management and clinical outcomes may differ among the subgroup of patients with emergency/urgent procedures. Purpose To describe periprocedural edoxaban management and clinical outcomes for patients in the EMIT-AF/VTE programme who underwent emergency/urgent procedures. Methods In this subanalysis, only physician-reported unplanned (emergency/urgent) procedures were included, of which dental and dermatological procedures were excluded. Only a patient’s first emergency procedure was included, with the exception of 3 patients having 2 procedures on the same day (in these cases the 2 procedures were combined). Procedure bleeding risk was classified according to EHRA criteria, and baseline characteristics and edoxaban interruption data were collected. Clinical event and procedure dates were compared to determine whether they were related. Results Among 156 patients undergoing emergency/urgent procedures, the mean ± standard deviation age at baseline was 74.5 ± 8.7 years, and the CHA2DS2-VASc score was 3.8 ± 1.6. Medical histories of hypertension and dyslipidaemia were reported in 84.0% and 40.4% of patients, respectively; approximately one-quarter of patients had diabetes mellitus (26.9%) or creatinine clearance ≤50 mL/min (24.4%). The most common procedure types were vascular access and transcatheter diagnostics/interventions (34.6%) and gastroenterological procedures (27.6%). Procedures were more often EHRA-classified as minor (35.9%) or low (35.3%) vs high risk (20.5%). Preprocedure edoxaban interruption rates ranged from 39.3%–50.9% across risk groups, with more than half of the procedures being performed with edoxaban interruption (53%–66%; Figure). By 20 days postprocedure, edoxaban therapy was resumed in approximately 86% and 88% of patients with minor- or low-risk procedures vs 70% with high-risk procedures. Overall, 33 clinical events were recorded, of which 18 (54.5%) preceded a procedure (Table). Five bleeding events and one thrombotic event occurred after and were caused by the procedure. Conclusions Edoxaban resumption was protracted after high- vs minor- or low-risk procedures. Bleeding and thrombotic events resulting from a procedure occurred in &amp;lt;4% of patients, indicating that postprocedure edoxaban therapy can be effectively tailored to optimise clinical outcomes.FigureTable

Analysis after posterior chamber phakic intraocular lens implantation: 17- to 19-year follow-up study.

To evaluate the clinical outcomes of the Visian implantable collamer lens (ICL) in eyes with ≥17 years of follow-up. Single-center. Retrospective observational study. 70 eyes from 38 patients who underwent surgery between 2002 and 2006 with V4 ICL implantation were analyzed. Preintervention data included corrected distance visual acuity (CDVA), refraction, and intraocular pressure (IOP). At the 19-year mark, CDVA, refraction, IOP, endothelial count, and vault were measured using Tomey Casia 2 anterior pole tomography, along with recording long-term events. The operated patients had a spherical correction between -4 diopters (D) and -21 D and a cylinder up to 7.5 D. The mean CDVA (decimal) at the 17-year check-up was 0.89 ± 0.18, with a spherical equivalent of -1.05 ± 1.36 D. IOP has remained stable because mean measurements before surgery and currently were 15.16 ± 2.54 mm Hg and 16.19 ± 3.29 mm Hg, respectively. The endothelial cell count showed values of 2191 ± 386 cells/mm2, with a maximum of 2804 cells and a minimum of 1125 cells. Finally, the vault obtained was 348.53 ± 234.58 mm. Over the years, 2 eyes developed angle-closure glaucoma and 9 eyes were operated on for the development of anterior subcapsular cataracts. Visian ICL implantation demonstrated long-term visual and refractive stability, indicating it as a low-risk procedure. The ICL V4 model yielded satisfactory results for myopia and astigmatism correction after 17 years.

Surgical aortic valve replacement in a patient with severe scoliosis

Aortic valve replacement for severe symptomatic Aortic stenosis is a low-risk procedure, but when compounded with coexisting conditions, procedural risk may increase. We present the case of a middle-aged female patient presenting with a constellation of complexities, including oblique sternum, severe dextroscoliosis, severe symptomatic aortic stenosis with bicuspid aortic valve, aortic root distortion, and a relatively rare blood group. Despite multiple problems, she underwent successful surgical aortic valve replacement. This case highlights the importance of a multidisciplinary approach in complex cardiac patients with the utmost need for a heart team concept for patient-centric decision-making.

Preoperative Angiographic Protocol for the Surgical Management of Spinal Dural Arteriovenous Fistulas: A Technical Nuance for Safe Minimally Invasive Surgery

BackgroundInterruption of the fistoulus point is the goal of the treatment of spinal dural arteriovenous fistula (dAVFs). Microsurgery still represents a highly efficient treatment in terms of complete occlusion with the lowest risk of recurrence rate. It is reported that the hardest step consists in finding the fistulous site itself, potentially extending surgical access and time, and increasing potential post-operative surgical-related complications. The accurate preoperative detection of the shunt and spinal level together is crucial for guiding optimal, fast and safe microsurgical treatment. MethodsIn the present paper, the authors describe a preoperative angiographic protocol for achieving a safe and simple resection of spinal dAVFs based on a six-year Institutional experience of forty-two patients who underwent minimally invasive. Two illustrative cases are also included in order to support the technical descriptions. ResultsThe suspected artery associated to the vascular malformation of interest is studied in our angiographic protocol through non-subtracted selective acquisitions in the lateral projection. The resulting frames are reconstructed with 3D Rotational Angiography. The implementation of the preoperative angiographic protocol allowed 100% of intraoperative identification of the fistoulus point in all cases with the use of minimally invasive approach. ConclusionsNowadays, neurosurgeons advocate for minimally invasive procedures and low morbidity risk procedures for the treatment of spinal dAVFs.Our preoperative approach for accurate angigoraphic localization of the fistoulus point through non-subtracted and 3D reconstructed angiography allowed to achieve safe and definitive occlusion of the shunt.

Temporarily Reversing Warfarin With Low-Dose 4-Factor Prothrombin Complex Concentrate in Left Ventricular Assist Device Patients Undergoing an Invasive Procedure.

American Association for Thoracic Surgery and The International Society for Heart and Lung Transplantation (AATS/ISHLT) guidelines recommend warfarin in patients with continuous-flow left ventricular assist devices (LVADs) to reduce the risk of device thrombosis and systemic embolization. Left ventricular assist device patients often undergo elective and emergent procedures that require interrupted anticoagulation. Data and experience vary on the optimal strategy to rapidly reverse warfarin in LVAD patients when an emergent procedure is planned. The purpose of this study was to describe the use of 4-factor prothrombin complex concentrate (PCC4) for warfarin reversal in patients with LVADs undergoing elective and emergent procedures. This retrospective, single-center, cohort review describes the use of PCC4 in patients with LVADs who require warfarin reversal for elective or emergent procedures. The primary outcome was a composite incidence of pump thrombosis, venous thromboembolism, and ischemic stroke within 30 days of PCC4 administration. In total, 14 patients received 17 administrations of PCC4. One patient received 3 administrations, and 1 other patient received 2 administrations during separate encounters. The median dose was 500 units or 6.6 units/kg (range = 4.2-14.1 units/kg). Of the PCC4 administrations, 82% (14/17) were for low bleed risk procedures and 76% (13/17) were for elective procedures. There were no cases of pump thrombosis, venous thromboembolism, or stroke within 30 days of the procedure. Low-dose PCC4 appears to be a safe and effective temporary reversal strategy for patients with LVADs undergoing low-bleed risk elective procedures.

Dentists’ Perspective on Osteoporosis Therapy: A Pilot Survey Study

Objective: Osteoporotic fractures are a major public health problem worldwide. Effective therapies have been available since 1995, with bisphosphonates (BPs) as the most used first-line drugs. Zoledronic acid and denosumab (Dmab) became available soon thereafter. However, both BPs and Dmab, but not other osteoporosis therapies, are associated with rare occurrences of osteonecrosis of the jaw (ONJ) and atypical femur fracture (AFF), the two most common major barriers either for initiating or maintaining effective anti-fracture therapies. In this pilot study, we aimed to determine dentists’ perceptions and practice patterns to mitigate ONJ. Methods: After approval from the Institutional Review Board, we e-mailed an online 7-point survey questionnaire to licensed dental practitioners, the members of the Michigan Dental Association (MDA), to ascertain the range of approaches dentists would take to treat patients who were using osteoporosis medications. Results: Members of the MDA were surveyed with a series of questions, and 40 responses were received. Respondents were 50% women, and 28 worked in suburban areas, 8 in urban areas, and 4 in rural areas. 48% of the dentists have been practicing for &gt; 20 years, 32% for 5–20 years, and 20% for &lt; 5 years. When asked about the interruption of osteoporosis medications for low-risk dental procedures, such as cavities, 68% never stopped therapy, 17% stopped in certain scenarios, and 15% reported stopping after a discussion with the patient’s provider. When asked about the interruption of osteoporosis medications for high-risk dental procedures, such as tooth extractions, 15% would not interrupt therapy, 23% would interrupt in certain scenarios, 7% would always interrupt therapy, and 55% would interrupt therapy after discussion with the patient’s provider. Conclusion: Despite the extreme rarity of ONJ, no specific guidelines exist from the American Dental Association (ADA), and dentists’ perspectives on mitigating ONJ are quite varied. Our study suggests that many dentists feel that osteoporosis therapy is a major barrier to safe dental practice and indicates an urgent need for education of our dentist colleagues on the rationale and validity of interrupting osteoporosis therapies.