Subsequent Surgical Removal Research Articles

Management of traumatic scalp arteriovenous fistula: Case report and literature review.

Blunt traumatic arteriovenous fistula (AVF) of scalp, are uncommon and most of them can be secured by simple embolization or surgical ligation of the feeders. Our goal in writing this paper is to show patients with traumatic scalp AVFs how to prevent complications and the likelihood of recurrence. Complete treatment and reduce the recurrence rate of traumatic AVF on the scalp. Traumatic scalp AVF. Transarterial embolization and surgical resection. Complete resection of the AVF and subsequent angiography showed resolution of the contralateral lesion. Combination of endovascular embolization with subsequent surgical removal may reduce intraoperative blood loss compared with surgery alone. In addition, a well-designed scalp flap can be performed based on the angiography findings after embolization.

Lameness and swelling of the metatarsus in a Saluki - Could it be an arteriovenous fistula?

A 12-year-old Saluki was presented with acute lameness and plantar swelling of the right metatarsus following an episode of free running. Radiographs showed soft tissue swelling only, the involved bone and joint structures were unremarkable. The lesion recurred several months later. Ultrasonographic imaging of the lesion revealed a well-vascularized cavernous structure. Subsequent surgical removal and histopathological examination of the structure raised the initial suspicion of an arteriovenous fistula, which was then confirmed histologically following a second surgical removal of another recurrence. The purpose of this case report is to illustrate the potential complexity of what initially appears to be a simple lameness. At the same time, attention is focused on the possibility that arteriovenous fistulas may tend to recur.

Dual-functional superhydrophobic coatings on biodegradable Mg alloys via nano-SiO2 particles assisted surface modification

In the exploration of next-generation biocompatible implant materials, magnesium (Mg) alloys have great potential due to their inherent biodegradability. The current study delineates the development of dual-functional coatings for Mg alloys, incorporating zinc (Zn) and calcium (Ca), characterized by both anti-bacterial and anti-corrosion attributes. These coatings were synthesized by integrating surface groups of magnesium hydroxide/magnesium oxide with surface atoms of nano‑silicon dioxide (nano-SiO2) particles, leading to the formation of magnesium silicate junctions. Subsequently, these interfacial surfaces were functionalized using organofluorosilanes. With the application of the coating, a notable enhancement in the static contact angle of water from 43.7° ± 1.1° to 158.4° ± 1.3° was observed. The anti-adhesive properties of the coating against bacteria were assessed through inoculation assays with Staphylococcus aureus, a predominant agent of implant-associated infections. No bacterial colonization on the Mg4Zn0.5Ca alloy surface was detected when the dual-functional coatings were applied. While a hydrogen evolution (HE) of 4.78 mL/cm2 was measured on uncoated surfaces, the HE reduced significantly to 0.35 mL/cm2 for coated alloy surfaces. Analysis using Nyquist plots unveiled a polarization resistance of coated surfaces that was an order of magnitude higher than uncoated surfaces. As a result, Mg alloys covered with a dual-functional nanocoating layer demonstrate favorable characteristics, such as diminished corrosion rates and enhanced resistance against bacterial adhesion. Such coatings negate the necessity for subsequent surgical removal of bone implants, consequently mitigating potential bacterial infections and the concomitant medical expenses.

Abstract B016: Eosinophils alter metastatic spread in pancreatic cancer

Abstract Pancreatic ductal adenocarcinoma (PDA) is the third most common cause of cancer death in the US with a 11% 5-year survival rate. A key contributor of this dismal prognosis is early and frequent metastatic spread with limited treatment options for patients. Metastasis in PDA is facilitated by a robust fibroinflammatory response in the primary tumor site, a large portion of which is composed of infiltrating immune cells, and survival during transit to establish in the secondary site. In the primary tumor reactive stroma, we found increased eosinophils in both human and mouse PDA compared to the normal pancreas. Eosinophils are an innate immune cell best known for their ability to control parasite responses and have been implicated in either pro- or anti-cancer roles in various solid tumors. We used the ΔdblGata mice, which lack eosinophils, to study the role of eosinophils during metastatic spread using a resectable model of PDA metastasis. This model of metastasis was developed to facilitate consistent seeding of lung metastasis in approximately 50 percent of mice from a transient subcutaneous tumor which undergoes subsequent surgical removal and harvest to evaluate metastasis at 4 weeks. We found that mice lacking eosinophils have increased metastasis to the lung in our resectable model of PDA metastasis but no difference in establishment of IV injected PDA tumor cells, suggesting eosinophil control at the primary tumor site. Single cell sequencing of the subcutaneous tumors finds differences in the angiogenic subtypes, tip and stalk cells, in mice lacking eosinophils. Sequencing of eosinophil populations in humans and mice find an increase in angiogenic signaling suggesting a regulatory role in tumor cell access to the circulation. We conclude that eosinophils in PDA inhibit the metastatic process through control of angiogenic signaling. Citation Format: Megan T. Hoffman, Patrick J. Lenehan, Jen Wang, Lestat Ali, Amiko Uchida, Sara Vayrynen, Andressa Dias Costa, Michael Dougan, Max Heckler, Jonathan Nowak, Brian W. Wolpin, Stephanie K. Dougan. Eosinophils alter metastatic spread in pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr B016.

A Case Report of Metal Induced MRI Accident and Diagnosis by Ultrasonography

Dental radiology has shown great developments in recent years. In addition to conventional radiography techniques, advanced imaging techniques are frequently used in dental radiology when necessary. Magnetic Resonance Imaging (MRI) is an advanced imaging technique that is frequently used because of its high soft tissue resolution and no risk of ionizing radiation. However, it should be noted that MRI also has some risks. Ultrasonography (USG) is a very useful technique for imaging foreign bodies especially superficial ones. The purpose of this case report was to present the USG diagnosis and subsequent surgical removal of a metallic foreign body that interferes with MRI in a cheek of 40 years old female. At the same time, it was aimed to draw attention to the disadvantages of metals for MRI and the role of USG in detecting superficial foreign bodies.

Cystoscopic Guided Laser Cauterization in a Dog with Complete Y-Type Urethral Duplication

Duplication of the urethra is a rare congenital malformation. A 14-month-old, sexually intact, male, Lagotto dog with complete Y-type urethral duplication was subjected to accessory urethra treatment for cystoscopic guided laser cauterization, with a 10-Watt diode laser with 550-micron fiber and 2.3 Fr outer diameter. The laser cauterization, that was repeated every 14 days for a total of three times, was performed by inserting the instrument from the accessory urethra outlet in the perianal area until it could be seen by the urethroscope, inside the ischial urethra. Nevertheless, this technique that proved to be non-invasive, less expensive than surgery, of short duration, and safe, did not allow the complete closure of the abnormal urethral tract. Therefore, the subsequent surgical removal of the accessory urethra was carried out. To the authors' knowledge this is the first report on the use of cystoscopic guided diode laser cauterization for accessory urethra treatment.

Abstract B018: Eosinophils alter metastatic spread in pancreatic cancer

Abstract Pancreatic ductal adenocarcinoma (PDA) is the third most common cause of cancer death in the US with a 11% 5-year survival rate. A key contributor of this dismal prognosis is early and frequent metastatic spread with limited treatment options for patients. Metastasis in PDA is facilitated by a robust fibroinflammatory response in the primary tumor site, a large portion of which is composed of infiltrating immune cells, and survival during transit to establish in the secondary site. In the primary tumor reactive stroma, we found increased eosinophils in both human and mouse PDA compared to the normal pancreas. Eosinophils are an innate immune cell best known for their ability to control parasite responses and have been implicated in either pro- or anti-cancer roles in various solid tumors. We used the ΔdblGata mice, which lack eosinophils, to study the role of eosinophils during metastatic spread using a resectable model of PDA metastasis. This model of metastasis was developed to facilitate consistent seeding of lung metastasis in approximately 50 percent of mice from a transient subcutaneous tumor which undergoes subsequent surgical removal and harvest to evaluate metastasis at 4 weeks. We found that mice lacking eosinophils have increased metastasis to the lung in our resectable model of PDA metastasis but no difference in establishment of IV injected PDA tumor cells, suggesting eosinophil control at the primary tumor site. Single cell sequencing of the subcutaneous tumors finds differences in the angiogenic subtypes, tip and stalk cells, in mice lacking eosinophils. Sequencing of eosinophil populations in humans and mice find an increase in angiogenic signaling suggesting a regulatory role in tumor cell access to the circulation. We conclude that eosinophils in PDA inhibit the metastatic process through control of angiogenic signaling. Citation Format: Megan T. Hoffman, Patrick J. Lenehan, Jennifer Wang, Lestat Ali, Li Qiang, Amiko Uchida, Sara Vayrynen, Andressa Dias Costa, Michael Dougan, Max Heckler, Jonathan Nowak, Brian W. Wolpin, Stephanie K. Dougan. Eosinophils alter metastatic spread in pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr B018.

Catheter-Directed Retrieval of an Infected Fragment in a Vietnam War Veteran.

Shrapnel injuries are commonly encountered in war zones. The severity of these injuries depends on the initial damage and both the anatomical and immune response at the time of injury or at more remote times in the case of reactivation. A veteran sustained a shrapnel injury to his left lower abdomen while serving in the Vietnam War. Nearly 50 years later, the patient presented with a recurrent retroperitoneal abscess associated with a residual fragment. In cooperation between interventional radiology and surgery, traditional endovascular techniques and devices were used to relocate an extravascular, secondarily infected fragment to an area more suitable for a minor surgical approach in the left inguinal region. Subsequent surgical excision and removal required only a superficial incision as opposed to a large retroperitoneal dissection, minimizing recovery time and allowing quick and full healing of the patient. This case demonstrates a multidisciplinary approach to transforming an otherwise large retroperitoneal dissection to a minimally invasive and technically efficient abscess drainage and foreign body retrieval.

Опыт ведения беременности высокой степени риска у больной миомой матки с эмболизацией маточных артерий в анамнезе

The increase in the frequency of uterine fibroids among women planning pregnancy is an actual problem. This pathology is the most common benign tumor of the female reproductive system, leading to complications during pregnancy and childbirth. One of the methods of surgical treatment of uterine fibroids in a significant number of patients is myomectomy. Patients with a history of uterine fibroids and myomectomy require close observation and a balanced choice of delivery tactics. This article describes a clinical case of high-grade management of a patient with uterine fibroids after embolization of the uterine nodes and subsequent surgical removal of the subserous node of uterine fibroids.

Management of Abdominal Pregnancy

<h3>Study Objective</h3> Abdominal pregnancy (AP) accounts for 1-2% of all extrauterine gestations and is associated with 80% perinatal mortality. Despite advancements in antenatal care and imaging, the standard management protocol for AP is not yet established. In this series, we report two cases of interval surgical management of AP following medical treatment. <h3>Design</h3> Case Series. <h3>Setting</h3> Academic institution. <h3>Patients or Participants</h3> Two patients. <h3>Interventions</h3> Pregnancy interruption medically and subsequent surgical removal. <h3>Measurements and Main Results</h3> Case 1 33-year-old P0 with history of uterine fibroids presents with abdominal pain. Imaging demonstrated a 12-week fetus in the rectouterine space. Fetal intracardiac KCl and intra-sac methotrexate were administered with a plan for close outpatient follow up. She re-presented with severe sepsis and underwent emergent surgery for pelvic abscesses. Case 2 37-year-old P0010 with a prior abdominal myomectomy at 13-weeks' gestation presented for scheduled antenatal ultrasound. AP was identified on the posterior uterine wall. Fetal intracranial digoxin was administered and the patient was followed with serial beta-human chorionic gonadotropin (bHCG). bHCG remained persistently elevated for 6 months and underwent robotic-assisted laparoscopic removal of products of conception. <h3>Conclusion</h3> Abdominal pregnancy is a rare and complex entity which encompasses a broad spectrum of clinical presentations. There is a range of methods described to manage AP with the majority of cases managed by primary surgical intervention. In this series, our cases of AP were initially managed medically, with planned interval surgery in order to decrease morbidity of primary surgical intervention. Possible complications related to AP include intra-abdominal hemorrhage, sepsis, and persistent products of conception. Currently, a consensus regarding the management of AP and related complications does not exist. We recommend a high clinical suspicion, multidisciplinary approach, and strict follow-up in order to optimize maternal outcomes.

Narrative review of theoretical considerations regarding HITHOC between past and future.

Hyppocrates constructed the medicines-surgery-energy triangle which includes all therapeutical modalities. Hyperthermic intraoperative chemotherapy (HITHOC) is a synergy-based single stage multimodality treatment encompassing the locoregional manifestation of the systemic malignant process. Pleural space, thermal effect, lavage/irrigation and chemotherapy represent the basic science ports of the network hub: HITHOC. The malignant transformation and process of the pleural surface (and underlying lung) challenges space management and tissue control. Thermotherapy without local chemotherapy is insufficient, similar to the normothermic local irrigation aligned with anticancer agents. The local administration of combined heat-transfer fluid and chemotherapy with or without subsequent surgical removal offers reasonable outcome in extensive primary pleural neoplasms (malignant mesothelioma), advanced (> Stage IIIA) NSCLC, functionally inoperable lung cancer and pleural carcinosis from extrathoracic malignancies. Measured by symptom-free survival and the quality of life, HITHOC in its present form, offers a modest yet fully substantiated solution. HITHOC in combination with the local application of targeted therapy and/or immunotherapy administered in the pleural space are currently under investigation. Additional development including new acting substances, their solvents and the means regarding surgical delivery and anesthesiology techniques are sign posts up ahead. Level 2 evidence are required in order to stepping up the recommendation levels, rewriting protocols and guidelines, in which HITHOC earns its revered position in the decision making process it deserves.

Stable oxime-crosslinked hyaluronan-based hydrogel as a biomimetic vitreous substitute

Vitreous substitutes are clinically used to maintain retinal apposition and preserve retinal function; yet the most used substitutes are gases and oils which have disadvantages including strict face-down positioning post-surgery and the need for subsequent surgical removal, respectively. We have engineered a vitreous substitute comprised of a novel hyaluronan-oxime crosslinked hydrogel. Hyaluronan, which is naturally abundant in the vitreous of the eye, is chemically modified to crosslink with poly(ethylene glycol)-tetraoxyamine via oxime chemistry to produce a vitreous substitute that has similar physical properties to the native vitreous including refractive index, density and transparency. The oxime hydrogel is cytocompatible in vitro with photoreceptors from mouse retinal explants and biocompatible in rabbit eyes as determined by histology of the inner nuclear layer and photoreceptors in the outer nuclear layer. The ocular pressure in the rabbit eyes was consistent over 56 d, demonstrating limited to no swelling. Our vitreous substitute was stable in vivo over 28 d after which it began to degrade, with approximately 50% loss by day 56. We confirmed that the implanted hydrogel did not impact retina function using electroretinography over 90 days versus eyes injected with balanced saline solution. This new oxime hydrogel provides a significant improvement over the status quo as a vitreous substitute.

Diode Laser Management of Primary Extranasopharyngeal Angiofibroma Presenting as Maxillary Epulis: Report of a Case and Literature Review.

Juvenile nasopharyngeal angiofibroma is a rare vascular neoplasm, mostly occurring in adolescent males, and representing 0.05% of all head and neck tumors. Nevertheless, it is usually recognized as the most common benign mesenchymal neoplasm of the nasopharynx. Usually, it originates from the posterolateral wall of the nasopharynx and, although histologically benign, classically shows a locally aggressive behavior with bone destruction as well as spreading through natural foramina and/or fissures to the nasopharynx, nasal and paranasal cavities, spheno-palatine foramen, infratemporal fossa and, very rarely, to the cranial cavity. Extranasopharyngeal angiofibroma is considered a distinct entity due to older age at presentation, different localizations (outside the nasopharyngeal pterygopalatine fossa) and attenuated clinical course. Extranasopharyngeal angiofibroma has been sporadically described in the oral cavity. We report a case of extranasopharyngeal angiofibroma with primary and exclusive involvement of the adherent gingiva of the anterior maxilla, managed by preoperative diode laser trans-mucosal photocoagulation and subsequent surgical removal. The current literature on primary extranasopharyngeal angiofibroma is also reviewed.

Targeting Nuclear NAD+ Synthesis Inhibits DNA Repair, Impairs Metabolic Adaptation and Increases Chemosensitivity of U-2OS Osteosarcoma Cells.

Osteosarcoma (OS) is the most common bone tumor in children and adolescents. Modern OS treatment, based on the combination of neoadjuvant chemotherapy (cisplatin + doxorubicin + methotrexate) with subsequent surgical removal of the primary tumor and metastases, has dramatically improved overall survival of OS patients. However, further research is needed to identify new therapeutic targets. Here we report that expression level of the nuclear NAD synthesis enzyme, nicotinamide mononucleotide adenylyltransferase-1 (NMNAT1), increases in U-2OS cells upon exposure to DNA damaging agents, suggesting the involvement of the enzyme in the DNA damage response. Moreover, genetic inactivation of NMNAT1 sensitizes U-2OS osteosarcoma cells to cisplatin, doxorubicin, or a combination of these two treatments. Increased cisplatin-induced cell death of NMNAT1−/− cells showed features of both apoptosis and necroptosis, as indicated by the protective effect of the caspase-3 inhibitor z-DEVD-FMK and the necroptosis inhibitor necrostatin-1. Activation of the DNA damage sensor enzyme poly(ADP-ribose) polymerase 1 (PARP1), a major consumer of NAD+ in the nucleus, was fully blocked by NMNAT1 inactivation, leading to increased DNA damage (phospho-H2AX foci). The PARP inhibitor, olaparib, sensitized wild type but not NMNAT1−/− cells to cisplatin-induced anti-clonogenic effects, suggesting that impaired PARP1 activity is important for chemosensitization. Cisplatin-induced cell death of NMNAT1−/− cells was also characterized by a marked drop in cellular ATP levels and impaired mitochondrial respiratory reserve capacity, highlighting the central role of compromised cellular bioenergetics in chemosensitization by NMNAT1 inactivation. Moreover, NMNAT1 cells also displayed markedly higher sensitivity to cisplatin when grown as spheroids in 3D culture. In summary, our work provides the first evidence that NMNAT1 is a promising therapeutic target for osteosarcoma and possibly other tumors as well.

Frequency and clinical impact of Dolichocolon in women submitted to surgery for rectosigmoid endometriosis

IntroductionRectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms. Material and methodsWe conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea. ResultsThirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group. ConclusionsDolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms.

Quality of life after laparoscopic removal of Essure® sterilization devices.

Objective(s)To assess changes in quality of life after laparoscopic removal of Essure® sterilization devices (Bayer AG, Leverkusen, Germany).Study DesignIn this prospective observational study in an academic research hospital, 80 women with new or worsening symptoms since placement of Essure® sterilization devices undergoing subsequent surgical removal were included. Laparoscopic removal of Essure® devices and salpingectomy with or without cornual excision were performed. Concomitant uterine procedures could be associated where indicated for gynaecological complaints. Comparison using the T student test for coupled series was done in this before-and-after study.ResultsHealth related quality of life (HRQL) was the primary outcome measured by the Short Form 12 (SF-12) questionnaire and a global 10 cm visual analogue scale (VAS). Secondary outcomes included assessment of pain, using continuous (VAS) and ordinal scales (Modified McGill Pain Questionnaire), menstrual bleeding (pictorial blood loss assessment chart (PBAC) score) and surgical feasibility and safety. There was a significant improvement in quality of life in both mental and physical health aspects of the SF-12 (34.02 (+/−1.19) vs. 49.61 (+/−1.42, P < .0001) and 36.55 (+/−0.99) vs. 43.32 (+/−1.18, P < .0001 respectively) as well as global VAS assessment (+2.91 (SD +/−0.27)) at the end of the first post-operative month. These improvements were maintained at three and six months. Mean pain decreased at one month following surgery compared to baseline (VAS 3.6 (+/−0.36) to 1.4 (+/−0.25), P < .0001 and McGill pain score 18.70 (+/−1.88) to 4.73 (+/−0.90), P < .0001). Improvements of a similar magnitude were observed when analysis was restricted to the 47 women without concomitant uterine surgery. No significant changes in bleeding were seen following of Essure® device removal. Planned procedures were all successfully completed.ConclusionLaparoscopic removal of Essure® devices in symptomatic women is technically successful and associated with short and medium-term improvement in quality of life as well as reduction in pelvic pain.

Cancer overdiagnosis: a biological challenge and clinical dilemma.

For cancer screening to be successful, it should primarily detect cancers with lethal potential or their precursors early, leading to therapy that reduces mortality and morbidity. Screening programmes have been successful for colon and cervical cancers, where subsequent surgical removal of precursor lesions has resulted in a reduction in cancer incidence and mortality. However, many types of cancer exhibit a range of heterogeneous behaviours and variable likelihoods ofprogression and death. Consequently, screening for some cancers may have minimal impact on mortality and may do more harm than good. Since the implementation of screening tests for certain cancers (for example, breast and prostate cancers), a spike in incidence of in situ and early-stage cancers has been observed, but a link to reduction in cancer-specific mortality has not been as clear. It is difficult to determine how many of these mortality reductions are due to screening and how many are due to improved treatments of tumours. In cancers with lower incidence but high mortality (for example, pancreatic cancer), screening has focused on high-risk populations, but challenges similar to those for general population screening remain, particularly with regard to finding lesions with difficult-to-characterize malignant potential (for example, intraductal papillary mucinous neoplasms). More sensitive screening methods are detecting smaller and smaller lesions, but this has not been accompanied by a comparable reduction in the incidence of invasive cancers. In this Opinion article, we focus on the contribution of screening in general and high-risk populations to overdiagnosis, the effects of overdiagnosis on patients and emerging strategies to reduce overdiagnosis of indolent cancers through an understanding of tumour heterogeneity, the biology of how cancers evolve and progress, the molecular and cellular features of early neoplasia and the dynamics of the interactions of early lesions with their surrounding tissue microenvironment.

SUN-410 Central Diabetes Insipidus Refractory to Oral Desmopressin (DDAVP)

Background We report a case of CDI due to craniopharyngioma resection that became refractory to oral DDAVP after recurrence of tumor and subsequent surgical removal. Due to inability of patient to use the intranasal route, subcutaneous (SC) DDAVP was used successfully. Clinical Case An 11-year male developed CDI after craniopharyngioma removal and proton beam therapy. He developed also panhypopituitarism, hypothalamic obesity, and had an impaired thirst mechanism. CDI was managed with oral DDAVP and fix fluid intake. After 2 years he had a tumor recurrence and a surgical removal complicated by a stroke. Since then his DDAVP dose had to be increased progressively due to poor CDI control. He presented to our hospital with severe hypernatremia and a urine output of 4-5 liters a day. DDAVP dose was eventually titrated up to 800 mcg bid. He was placed on minimum fluid intake of 3 Liters a day. Even with this dose he was putting out 4 liters of urine daily. Intranasal DDAVP was not considered due to poor cooperation of patient and nasal mucosa scarring. SC DDAVP was started at a dose of 1 mcg (0.01 mcg/Kg) twice a day.Dose increments were made by 0.5 mcg every 2 days to avoid hyponatremia. Prior to therapy patient received 4 liters/day and was progressively decreased, as DDAVP dose was increased, to 1.7 liters/day. Patient was discharged home on 4.5 mcg in the morning and 5.5 mcg at night time (0.14 mcg/kg/day). Discussion The route of administration of DDAVP varies depending on the age and cooperation of the patient to use the different forms available. DDAVP has also haemostatic effect. It is used in the treatment or to prevent bleeding in patients with von Willebrand disease, haemophilia A and platelet function defects. We hypothesize that our patient became resistant to the action of oral DDAVP probably due to the development of antibodies that were interfering with the appropriate absorption from the gastrointestinal tract. The parenteral/SC route dose ranges from 0.1-1 mcg in one or two divided doses nevertheless our patient had a stroke and we were concerned about the maximum dose that it could be used without increasing the risk of causing a new thrombotic event. With no data available about the use of DDAVP in this specific setting, we decided to use as a limit the dose used to treat bleeding disorders (0.3 mcg/Kg).Since our patient had basically an adult weight (70kg) we have enough room to continue increasing the dose up until desire effect was reached keeping in mind that 20 mcg/day is the maximum dose used in adults with bleeding disorders. Since discharge his sodium has remained stable as also his urine output and he has been able to reassume his daily activities. Conclusion: We present a case of CDI refractory to oral DDAVP.SC DDAVP was used and after slow titration patient was able to reach stable sodium levels and urine output with no side effects. Final dose was less than 50% of the dose used to treat bleeding disorders.

Outcome following computed tomographic imaging and subsequent surgical removal of keratomas in equids: 32 cases (2005-2016).

OBJECTIVE To describe the use of CT in the diagnosis of and presurgical planning for equids with keratomas treated by hoof wall resection and determine postoperative complications and outcome. DESIGN Retrospective case series. ANIMALS 29 horses and 3 mules with keratomas treated by partial or complete hoof wall resection following CT imaging of the distal portion of the affected extremity from 2005 through 2016. PROCEDURES For each equid, physical examination and lameness evaluation were performed, followed by imaging of the distal portion of the affected extremity. A tentative diagnosis of keratoma was made given results of clinical, radiographic, and CT examination, with the definitive diagnosis made on histologic examination. After CT imaging, each equid was treated with hoof wall resection. RESULTS CT allowed accurate identification of the size and location of 35 keratomas in 33 feet. Thirty equids underwent partial and 2 underwent complete hoof wall resection for keratoma removal. Complications developed in 4 of 31 (13%) equids and included excessive granulation tissue formation at the surgical site (n = 1), excessive granulation tissue formation and worsening lameness (1), incomplete keratoma removal with suspected regrowth (1), and incomplete healing of the surgical site with distal interphalangeal joint sepsis secondary to repeated debridement of abnormal tissue (1). Twenty-eight of 31 (90%) equids returned to their previous activity level. CONCLUSIONS AND CLINICAL RELEVANCE Preoperative CT examination of the feet was useful in the diagnosis of and surgical planning for keratomas in equids. A low complication rate was achieved with the described techniques.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease.

ObjectiveTo describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).MethodsA single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.ResultsForty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.ConclusionHybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.