Multiple Revisions Research Articles

Intraventricular entrapment of shunt catheter causing shunt malfunction

Abstract Intraventricular septations can lead to compartmentalization of the ventricles that can result in “complex or loculated hydrocephalus”. We report a case of 7 year old female child who underwent multiple shunt revisions where there was intraventricular entrapment of shunt catheter leading to obstruction of the shunt and malfunction. In present case we placed the ventricular catheter in contra-lateral ventricle with good clinical outcome. With the recent advancements endoscopic guided removal of the old malfunctioning ventricular catheters is considered the safest option.

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery

Background:With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery.Methods:The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data.Results:Decisions pertaining to “immediate implant-based breast reconstruction” were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection.Conclusions:Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.

Shunt revision requirements after posthemorrhagic hydrocephalus of prematurity: insight into the time course of shunt dependency.

Intraventricular hemorrhage (IVH) is a common affliction of preterm infants and often results in posthemorrhagic hydrocephalus (PHH). These patients typically eventually require permanent CSF diversion and are presumed to be indefinitely shunt-dependent. To date, however, there has been no study of long-term shunt revision requirements in patients with PHH. We analyzed retrospectively collected data for 89 preterm patients diagnosed with grades III and IV IVH and PHH at our institution from 1998 to 2011. Sixty-nine out of 89 patients (77.5%) underwent ventriculoperitoneal (VP) shunt placement, and 33 (47.8%) required at least one shunt revision and 18 (26.1%) required multiple revisions. The mean ± standard deviation follow-up time for shunted patients was 5.0 ± 3.3 years. The majority of early failures were due to proximal catheter malfunction, while later failures were mostly due to distal catheter problems. There was a significant difference in the number of patients requiring revisions in the first 3 years following initial VP shunt insertion compared after 3 years, with 28 revisions versus 10 (p < 0.004). In 8 out of 10 patients who underwent shunt revisions after 3 years, evidence of obstructive hydrocephalus was found on imaging either in the form of an isolated fourth ventricular cyst or aqueductal stenosis. Our results suggest that in a distinct subset of patients with PHH, obstructive hydrocephalus may develop, resulting in long-term dependence on CSF diversion. Further study on the factors associated with long-term shunt dependence and revision requirements within the PHH group is warranted.

Association of malignancy with repeat diagnostic CT in small children

The article on “potential association of malignancy and repeat diagnostic computerized tomography (CT) in children with ventriculoperitoneal shunts: Report of two cases” published in J Pediatr Neurol made interesting reading [1]. A similar case was encountered by us. A 16-year-old male boy had undergone nearly 17 CT scan screenings during the first 3.5 year’s of his life for shunt blocks. Thirteen of 17 CT scans were done within the age of 2 years (7 within 6 month of life), the first one was performed within a week following his birth. The ventriculoperitoneal shunt was done for post hemorrhagic hydrocephalus and he required multiple revisions following first installation. The boy attended our outpatient department for swelling in the neck and difficulty in cognition. Examination revealed a cervical and submandibular lymphadenopathy and compromise of higher mental functions. The other lymph nodes were not enlarged on palpation. The cervical lymph nodes were soft and discrete, while few submandibular nodes were matted. There was no organic involvement on further screening of abdomen and chest, the bone marrow evaluation was done at hematology department. The excisional biopsy of submandibular lymph

Vintage errors: do real-time economic data improve election forecasts?

Economic performance is a key component of most election forecasts. When fitting models, however, most forecasters unwittingly assume that the actual state of the economy, a state best estimated by the multiple periodic revisions to official macroeconomic statistics, drives voter behavior. The difference in macroeconomic estimates between revised and original data vintages can be substantial, commonly over 100% (two-fold) for economic growth estimates, making the choice of which data release to use important for the predictive validity of a model. We systematically compare the predictions of four forecasting models for numerous US presidential elections using real-time and vintage data. We find that newer data are not better data for election forecasting: forecasting error increases with data revisions. This result suggests that voter perceptions of economic growth are influenced more by media reports about the economy, which are based on initial economic estimates, than by the actual state of the economy.

Outcomes of Male Sling Mesh Kit Placement in Patients with Neuropathic Stress Urinary Incontinence: A Single Institution Experience

Background and Objectives: The mainstay of therapy in patients with neuropathic stress urinary incontinence (nSUI) has been through the use of artificial urinary sphincter (AUS). AUS infection/erosion rates are higher in nSUI patients and these patients tend to be younger, increasing the likelihood of multiple AUS revisions in the future. We review our experience with mesh male slings for patients with nSUI. Methods: A retrospective review of patients who had mesh sling placement. Results: Twenty patients were identified between 2003 and 2011. 14/20 (70%) (5 = AdVance, 8 = InVance, 1 = Virtue) were available for long-term evaluation; in 6/20 (30%) the sling was removed for either infection or perineal wound breakdown. The mean time from injury to male sling was 148.2 (29-449) months. Pre-/post-op fluorourodynamic study was performed in 13 and 7 patients, respectively. There were no significant differences in ALPP (46.4 vs. 55.7 cm H₂O, p = 0.106) and MCC (456.6 vs. 608 ml, p = 0.21) in the 7 patients who had a post-op study: five patients had new onset low bladder compliance and two had new onset detrusor overactivity post-sling. With a mean follow-up of 24.7 (1-66) months, 4/14 (28.6%) had no UI. Conclusions: With short-term follow-up, mesh male slings are a feasible option to treat nSUI. There appears to be a lower success rate for UI resolution, which may be attributable to new onset detrusor failure or wound infection requiring sling removal.

Short stem total hip arthroplasty in patients with rheumatoid arthritis.

Total hip arthroplasty (THA) has proven successful in patients with rheumatoid arthritis (RA). Patients with RA often require multiple revisions, and bone conservation is mandatory. A variety of short stems is currently available with mid-term results for osteoarthritis. This retrospective study evaluated mid-term clinical results of short stem THA in a series of patients with RA. Between 2005 and 2009, a total of 105 cementless short stems were implanted in patients with RA. Average patient age at the time of the index THA was 44.2 years, and average length of follow-up was 5 years. Clinical evaluation included physical examination and documentation of potential adverse events during the postoperative period. No radiographic failures occurred. Femoral and cup components showed some minor radiolucencies with sclerotic lines, but none involved 100% of the bone-prosthesis interface. Complications included femoral component subsidence in 2 hips after initial full weight bearing; 1 case resolved after 3 months, and the other case was revised to a standard shaft. One intraoperative dorsolateral stem tip perforation occurred with revision to a conventional length stem. Migration in 1 cup led to revision without removal of the short stem implant. No infections or joint dislocations were observed. The transfer of the short stem concept to an additional treatment option for patients with RA proved successful in the early to mid-term postoperative period. Complications and revisions were limited to early migration and early loosening of the implants in line with the results reported in the literature of cementless conventional THA in patients with RA.

Postshunt lateral ventricular volume, white matter integrity, and intellectual outcomes in spina bifida and hydrocephalus.

No previous reports exist that have evaluated the relationships of white matter (WM) integrity with the number of shunt revisions, ventricular volume after shunting, and cognition in medically stable children who have spina bifida and hydrocephalus (SBH). The authors hypothesized that enlarged ventricles and a greater number of shunt revisions decrease WM integrity in children. In total, 80 children (mean age 13.7 years) who had SBH underwent MRI and IQ testing. Probabilistic diffusion tractography was performed to determine mean diffusion tensor imaging (DTI) metrics along the frontal and parietal tectocortical pathways. The DTI metrics were evaluated for significant correlation with a composite IQ measure and with the total number of shunt revisions and the total lateral ventricular volume obtained through semiautomated parcellation of T1-weighted MRI scans. An enlargement in total lateral ventricle volume and an increase in the number of shunt revisions were both associated with higher fractional anisotropy (FA) and with lower radial diffusivity (RD) along both frontal and parietal tectocortical pathways. Children who had not undergone a shunt revision had on average a greater lateral ventricle volume and higher FA and lower RD along frontal and parietal pathways than those who had undergone multiple shunt revisions. The mean DTI metrics along parietal pathways predicted IQ scores, but intellectual ability was not significantly correlated with ventricular volume or with the number of lifetime shunt revisions. Significant changes in DTI metrics were observed as a function of ventricular volume. An increased lateral ventricle volume was associated with elevated FA and decreased RD. Given that the participants were medically stable at the time of the MRI examination, the results suggested that those who have enlarged ventricles show a DTI pattern consistent with axonal compression due to increased intracranial pressure (ICP) in attenuated hydrocephalus. Although limited by a cross-sectional design, the study's findings suggest that DTI metrics may serve as sensitive indicators for chronic, mild hydrocephalus in the absence of overt clinical symptoms due to increased ICP. Having enlarged ventricles and undergoing multiple shunt revisions did not affect intellectual ability in children with SBH.

The association between metal allergy, total knee arthroplasty, and revision

Background and purpose — It is unclear whether delayed-type hypersensitivity reactions against implanted metals play a role in the etiopathogenesis of malfunctioning total knee arthroplasties. We therefore evaluated the association between metal allergy, defined as a positive patch test reaction to common metal allergens, and revision surgery in patients who underwent knee arthroplasty.Patients and methods — The nationwide Danish Knee Arthroplasty Register, including all knee-implanted patients and revisions in Denmark after 1997 (n = 46,407), was crosslinked with a contact allergy patch test database from the greater Copenhagen area (n = 27,020).Results — 327 patients were registered in both databases. The prevalence of contact allergy to nickel, chromium, and cobalt was comparable in patients with and without revision surgery. However, in patients with 2 or more episodes of revision surgery, the prevalence of cobalt and chromium allergy was markedly higher. Metal allergy that was diagnosed before implant surgery appeared not to increase the risk of implant failure and revision surgery.Interpretation — While we could not confirm that a positive patch test reaction to common metals is associated with complications and revision surgery after knee arthroplasty, metal allergy may be a contributor to the multifactorial pathogenesis of implant failure in some cases. In cases with multiple revisions, cobalt and chromium allergies appear to be more frequent.

Case Report of Multiple Tracheostomy Revisions due to Persistent, Recurrent Cuff Leak.

This case is a patient with amyotrophic lateral sclerosis who was unable to be separated from mechanical ventilator support and required a tracheostomy. The patient underwent an initial open tracheostomy utilizing flexible fiberoptic tracheoscopy (FFT) in the operating room (OR). Subsequently, he developed recurrent leaks in the tracheal tube cuff requiring multiple trips back to the operating room. The recurrent cuff leak occurred following each tube placement until the etiology of the leak was discovered during the fourth procedure. In the fourth procedure, the wound was explored more extensively, and it was found that there was a sharp, calcified, aberrant fragment of a tracheal cartilage ring protruding into the tracheal lumen, which was damaging the cuff of each tube. This fragment was not visible by multiple FFTs, nor was it visible in the wound by the surgeons until wider exploration of the wound occurred. The cartilage fragment was ultimately excised and the patient had no further cuff leaks. Aberrant tracheal cartilage should be on the differential diagnosis for cuff leaks subsequent to surgical tracheostomy (ST) or percutaneous dilatational tracheostomy (PDT).

Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach

ABSTRACT Purpose In a previous work, we presented a protocol for the management of patients with complex pelviperineal injuries (CPI) resulting from blunt trauma. This treatment protocol included: early hemorrhage control, surgical debridement of devitalized tissue, selective loop transverse colostomy according to the location of the perineal wound, distal colonic irrigation with saline solution, pulsatile saline solution irrigation of the perineal wound, maintenance of the perineal wound open, management of bone fractures and visceral injuries, surgical revisions at intervals of 24 to 48 hours, presumptive antibiotic therapy, early nutritional support, and definitive repair of wound defect and visceral injuries after infection control and metabolic recovery. In order to determine whether the evolution of the authors's protocol for the assessment and management of patients with CPI is associated with improved patient outcome we conduct this review. Materials and methods The medical records of 42 patients with CPI resulting from blunt trauma admitted in the level I trauma center at the HC-USPSM, were reviewed. Demographic data, mechanism of trauma, revised trauma score (RTS) and injury severity score (ISS), classification of perineal injuries, associated systemic trauma, infection complications and mortality rates (overall, early and late) were collected. Results The early mortality was 19% and the late mortality was 17%. The overall mortality was 36%. Patients who died had higher average ISS (average ISS = 45) comparing to patients who survived (average ISS = 25) with significant statistical difference (p &lt; 0.05). Damage control principles applied to CPI was the standard of care and a selective approach to perform fecal stream diversion were used. Conclusion The results of this study showed that the use of this protocol was effective and reinforced the importance of the priority in early control of hemorrhage, early fecal diversion in selected cases, multiple surgical perineal revisions, and avoidance of complex visceral injury repair at the first surgical intervention. How to cite this article Teixeira Jr FJR, do Couto Netto SD, Collete e Silva FS, Mori ND, Fontes B, Poggetti RS, Birolini D, Bernini CO, Utiyama EM. Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach. Panam J Trauma Crit Care Emerg Surg 2015;4(2):87-95.

Over-drainage and persistent shunt-dependency in patients with idiopathic intracranial hypertension treated with shunts and bariatric surgery.

Background:Idiopathic intracranial hypertension (IIH) may lead to visual impairment. Shunt surgery is indicated for refractory IIH-related symptoms that persist despite medical treatment, or those presenting with significant visual decline. Obesity is a risk factor for IIH; a reduction in weight has been shown to improve papilledema. Bariatric surgery (BS) has been suggested for treating IIH associated with morbid obesity. In this study, we describe a high rate of over-drainage (OD) seen in patients following shunts and BS.Methods:The study cohort includes 13 patients with IIH that underwent shunt surgery for treatment of the IIH-related symptoms. Six patients underwent BS in addition to the shunt surgery (but not concomitantly). Seven patients had only shunt surgeries with no BS. Data were collected retrospectively.Results:BS effectively led to weight reduction (body mass index decreasing from 43 ± 4 to 28 ± 5). Patients undergoing BS had 1–6 (2.5 ± 1.9) shunt revisions for OD following BS, as opposed to 0–3 (1.4 ± 1.1) revisions prior to BS over similar time spans (statistically insignificant difference), and 0–6 (1.6 ± 2.5) revisions among the non-BS patients over a longer time span (statistically insignificant difference). Two patients in the BS group underwent shunt externalization and closure; however, they proved to be shunt-dependent.Conclusions:Patients with IIH that undergo shunt surgery and BS (not concomitantly) may suffer from OD symptoms, necessitating multiple shunt revisions, and valve upgrades. Despite BS being a valid primary treatment for some patients with IIH, among shunted patients, BS may not lead to resolution of IIH-related symptoms and patients may remain shunt-dependent.

Shunt revision requirements after posthemorrhagic hydrocephalus of prematurity: insight into the time course of shunt dependency

Results 69 out of 89 patients (77.5%) underwent VP shunt placement, and 33 (47.8%) required at least one shunt revision and 18 (26.1%) required multiple revisions. The mean ± standard deviation follow-up time for shunted patients was 5.0 ± 3.3 years. The majority of early failures are due to proximal catheter malfunction, while later failures were mostly due to distal catheter problems. There was a significant difference in the number of patients requiring revisions in the first three years following initial VP shunt insertion compared after three years, with 28 revisions versus 10 (p<0.004). In the 10 patients who underwent shunt revisions after three years, evidence of obstructive hydrocephalus was found on imaging either in the form of an isolated fourth ventricular cyst or aqueductal stenosis. Conclusions Our results suggest that in a distinct subset of patients with PHH, obstructive hydrocephalus may develop, resulting in long-term dependence on CSF diversion. Further study on the factors associated with long-term shunt dependence and revision requirements within the PHH group is warranted.

Contemporary Update on the Treatment of Dog Bite: Injuries to the Oral and Maxillofacial Region

The purpose of the present retrospective record review was to evaluate the patient demographics, treatment rendered, and long-term outcomes of patients injured in dog bite attacks to the oral and maxillofacial region. In the present study, a retrospective medical record review was conducted of patients treated by the oral and maxillofacial surgery department at the University of Tennessee Medical Center who had presented with injuries to the head, neck, and face region from dog bite attacks from February 1, 2006 to October 31, 2013. Each patient included had to have had at least 1 follow-up visit. The data obtained from the patients' medical records included patient demographics, event details, injuries sustained, and treatment rendered and analyzed. The medical records from 20 patients were included and reviewed. More than one half (60%) of the patients were younger than 12 years old. The dog was owned by the patient or a relative in 58% of the cases. The children sustained injuries requiring hospital admission and repair in an operating room setting more often than did the adults. Pit bulls were more frequently associated with injuries than other breeds (9 of 20). Our patients required a total of 28 hospital inpatient days, 29 total procedures, and follow-up treatment for up to 2 years. Our review has shown the complexity of soft tissue injury treatment and the significant financial impact associated with dog bite injuries owing to the multiple hospital admissions, surgical revisions, and lengthy follow-up period required.

Ultrasound-guided peripheral nerve blocks for ventricular shunt revision in children.

We describe using ultrasound-guided peripheral nerve blocks for postoperative pain control in 2 children undergoing ventricular shunt surgery. In the first patient undergoing ventriculo-peritoneal shunt revision, a combination of ultrasound-guided greater occipital nerve, superficial cervical plexus, and transversus abdominis plane blocks was used. In the second patient undergoing ventriculo-pleural shunt revision, a combination of ultrasound-guided greater occipital nerve, superficial cervical plexus, and intercostal blocks was used. Both patients, who underwent multiple revisions during their hospitalizations, showed decreased analgesic requirements after regional anesthesia. Our experience suggests this combined block technique may provide beneficial postoperative analgesia for patients undergoing shunt revision.

Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre.

A two-stage revision remains the gold standard to eradicate deep infection in total knee arthroplasty. Higher failure rates are associated with a number of factors including poly-microbial infections, multiresistant organisms and previous operations. The aims are to investigate [1] the overall success rate of a two-stage revision for infections in TKA, [2] the outcome of repeat two-stage revisions in recurrent infections and [3] the factors affecting the outcomes of such cases. We present the outcomes of a consecutive, retrospective case series of 51 periprosthetic joint infections managed with a two-stage revision knee arthroplasty over a three year period. Forty-six (90%) of 51 were referred from other hospitals. Infection was successfully eradicated in 24 (65%) of 37 patients undergoing an initial two-stage procedure. Following a failed two-stage revision, a repeat two-stage revision was performed in 19 patients eradicating infection in 8 (42%). A third two-stage was performed in five of these patients eradicating infection in three with an average follow-up of 43 months. Multidrug resistance was present in 69%, and 47% of the patients were infected with multiple organisms. All unsuccessful outcomes involved at least one multidrug-resistant organism compared to 43% in the successful cohort (P=0.0002). Serological markers prior to a second-stage procedure were not significantly different between successful and unsuccessful outcome groups. Single or multiple two-stage revisions can eradicate infection despite previous failed attempts. In this series, failure is associated with multidrug resistance, previous failed attempts to eradicate infection and a less favourable host response.

The Role of a Plastic Surgeon in Complex Joint Reconstruction

BACKGROUND: 160,000 hip and knee replacements are performed each year in the UK. After multiple revisions, soft tissues become sub-optimal and chronic wounds develop causing infection or metalwork extrusion.1–5 We present our experience with 83 patients at a tertiary orthopaedic hospital. METHODS: A prospective chart review of patients whom required reconstruction as a result of complex joint revision surgery was performed between February 2006 and February 2014. All primary joint replacements were excluded. RESULTS: 83 operations were performed which were separated down into the following categories: Group 1 (n=18) had acute wound breakdown and exposed metalwork but no laboratory evidence of infection. Group 2 (n=29) had delayed wound breakdown (1-6 weeks post-operatively) with positive bacteriology but no raised inflammatory markers. Group 3 (n=36) had longstanding wound breakdown with positive bacteriology and raised inflammatory markers. 47 belonged to Group 1 or 2 and were as performed as an emergency with metalwork being left In Situ. Group 3 were subdivided into Group 3a (n=5) where revision and reconstruction occurred in a single stage and Group 3b (n=31) managed by a two-stage reconstruction, with metalwork being replaced by an anti-microbial spacer and flap coverage of the wound. The second stage should be planned once biochemical parameters have normalised after being 6 weeks free of antibiotics. A total of 15 different types of flap were used. The average age was 67.5 years and mean follow-up 14 months (1-29 months). The long-term success rate was 85% of patients being ambulant and infection free at 6 months. CONCLUSIONS: The best results are achieved using a combined approach with multi-disciplinary input from orthopaedic and plastic surgeons with constant specialist clinical microbiology input. All patients had deep tissue samples taken, a long-line inserted and according to microbiology advice, a tailored 6-week regime of intravenous antibiotics. A two-stage approach improves outcomes of chronic wounds however patients often have multiple co-morbidities that necessitate a single-stage plan.

Developing an index for the orthodontic treatment need in paediatric patients with obstructive sleep apnoea: a protocol for a novel communication tool between physicians and orthodontists

IntroductionSleep disordered breathing in the paediatric population can manifest as an array of different systemic symptoms; among them is a distinct malocclusion and craniofacial phenotype. Emerging research suggests that the...

Medication overuse headache – An under-diagnosed problem in shunted idiopathic intracranial hypertension patients

Purpose. Management of headache in a subgroup of shunted idiopathic intracranial hypertension (IIH) patients is a well- described and difficult task. We present our series of shunted IIH patients with medication overuse headache (MOH) and discuss the role of careful pain management in this group of patients. Materials and methods. A retrospective review of shunted IIH patients with headache, who had their shunt function assessed by monitoring their intracranial pressure and were subsequently diagnosed with MOH. Results. A total of 15 patients were identified. The mean time between the diagnosis of IIH and the diagnosis of medication overuse headache was 6 years (standard deviation 4.9, range 2–18 years). The majority of patients in this group (12/15) had undergone multiple shunt revisions. Conclusions. Medication overuse headache in shunted IIH patients can lead to the requirement of hospital admission, investigations and procedures. We suggest that opiates and non-steroidal anti-inflammatory analgesics (NSAIDs) are used for a specified duration post-operatively and reviewed regularly. We suggest that patients are counselled regarding medication overuse headache in a multidisciplinary setting.

Remote Sensing Open Access Journal: Increasing Impact through Quality Publications

Remote Sensing, an open access journal (https://www.mdpi.com/journal/remotesensing) has grown at rapid pace since its first publication five years ago, and has acquired a strong reputation. It is a “pathfinder” being the first open access journal in remote sensing. For those academics who were used to waiting a year or two for their peer-reviewed scientific work to be reviewed, revised, edited, and published, Remote Sensing offers a publication time frame that is unheard of (in most cases, less than four months). However, we do this after multiple peer-reviews, multiple revisions, much editorial scrutiny and decision-making, and professional editing by an editorial office before a paper is published online in our tight time frame, bringing a paradigm shift in scientific publication. As a result, there has been a swift increase in submissions of higher and higher quality manuscripts from the best authors and institutes working on Remote Sensing, Geographic Information Systems (GIS), Global Navigation Satellite System (GNSS), GIScience, and all related geospatial science and technologies from around the world. The purpose of this editorial is to update everyone interested in Remote Sensing on the progress made over the last year, and provide an outline of our vision for the immediate future. [...]