Unplanned Intervention Research Articles

IMPACT OF WATERLOGGING ON LAND USE, BIODIVERSITY AND ECOSYSTEM SERVICES IN TALA UPAZILA, BANGLADESH

Waterlogging has become a major issue due to its severe impact on the south-western region of Bangladesh. This study aims to assess the trend of waterlogging and to find out the impact of waterlogging on land use, biodiversity and ecosystem services in the Tala located in the south-western region of Bangladesh. Satellite images of 1990, 2000, 2010 and 2021 were analyzed to portray the trend of waterlogging and questionnaire survey, FGDs and KIIs were used to discover the impacts of waterlogging on land use, biodiversity and ecosystem services in the study area. Satellite image analysis has shown that there is an ascending trend (increased by 154.5% between 1990 and 2000, by 135.9% between 2000 and 2010 and by 23.6% between 2010 and 2021) of waterlogging in the Tala upazila. Qualitative investigations revealed that waterlogging due to siltation in the associated rivers and unplanned human interventions, has been posing threats to the crop lands by turning them marshy. Biodiversity of aquaculture species, agricultural crops, aquatic wild animals, livestock, trees, birds etc. have been severely affected by waterlogging. Waterlogging is highly responsible for the low production of crop and aquaculture species, shortage of safe drinking water, habitat loss, sanitization, migration of people and so on.

Cholesterol crystal dissolution rate of serum is associated with iliofemoral calcification and predicts outcomes in patients undergoing TAVR

Abstract Background Calcific Aortic stenosis (AS) has several findings in common with atherosclerosis including inflammation and lipoprotein deposition. Histopathological examination has revealed atherosclerotic lesions, that mainly contain cholesterol crystals (CC) in resected AS cusps. Previous studies have demonstrated that CCs can activate the NLRP3 inflammasome, resulting in an IL-1 driven systemic inflammation, that leads to the development of atherosclerotic plaques. Aims Our aim was to quantify the endogenous cholesterol crystal dissolution rate (CCDR) in AS patients undergoing TAVR. We sought to examine whether CCDR may be associated with iliofemoral calcification and suitable for identifying patients at high risk for vascular complications and increased mortality. Methods The study included 348 AS patients undergoing TAVR. Pre-interventional computed tomography (CT) scans were analyzed to quantify iliofemoral calcification from the femoral artery bifurcation to the aortic bifurcation. The CCDR was measured using flow cytometry to enumerate CC, that were added to a serum solution, at baseline and after two hours of incubation. The dissolution capacity was indicated as percentage change in CC count at baseline and after incubation. The study cohort was stratified according to the median CCDC into high and low CC dissolvers. Results The study population had a mean age of 80.9±6.2 years. CT-based calcium assessment revealed significantly higher right as well as left iliofemoral calcification in low CC dissolvers as compared to high CC dissolvers (1280 vs 1083 mm3, p=0.03; 1292 vs 1043 mm3, p=0.04, respectively). Consistently, an unplanned endovascular intervention for access-related vascular injury was needed more frequently in patients with a low CCDR, as compared to patients with a high CCDR (20.5% vs 12.2%, p=0.04), Figure 1. However, the rate of major vascular complications tended to be higher in the low CCDR group (3.4%) as compared to the high CCDR group (0.6%) but was not significantly different (p=0.12). The one-year all-cause mortality was significantly higher in patients with a low CCDR (13.6%) as compared to patients with a high CCDR (7.0%, p=0.05). This difference was mainly driven by significantly increased cardiovascular death in low CC dissolvers (9.1% vs 1.7%, p=0.03), whereas non-cardiovascular mortality rates were similar between both groups (5.1% vs 5.2%, p=0.81). In multivariate analysis, only low CCDR (OR: 2.51 [95% CI: 1.02 – 6.15], p=0.05) and Albumin (OR: 0.88 [95% CI: 0.79 – 0.98], p=0.03) were independently associated with one-year mortality following TAVR. Conclusion The CCDR is a novel biomarker associated with outcomes in AS patients undergoing TAVR. We have demonstrated, that a low CCDR is associated with increased iliofemoral calcification and vascular injury as well as one-year mortality. Thus, CCDR may provide additional prognostic information to identify vulnerable patients beyond classic risk assessment.Figure 1

Eight-year follow-up of cardiosphere-derived cell transplantation in patients with single ventricle congenital heart disease

Abstract Background Although transcoronary infusion of cardiosphere-derived cells (CDCs) in patients with single ventricles provides short-term improvement in cardiac function, the long-term efficacy is still unknown. Purpose: We tested the hypothesis that CDC infusion is associated with improved long-term clinical outcome in patients with single ventricles and heart failure. Methods: Patients were enrolled in the TICAP phase 1 (Transcoronary Infusion of Cardiac Progenitor Cells in Patients With Single Ventricle Physiology) and PERSEUS phase 2 (Cardiac Progenitor Cell Infusion to Treat Univentricular Heart Disease) trials between January 5, 2011, and January 30, 2015. The inclusion criteria were that patients were aged <6 years who were diagnosed with single ventricle lesions undergoing stage 2 (bidirectional Glenn: BDG) or stage 3 (total cavopulmonary connection: TCPC) palliation. Ventricular ejection fraction should be <60% during the initial screening through the final enrollment. Medical records of patients with single ventricles were obtained and analyzed as a control group who were eligible but were treated by staged palliation alone. We evaluated the effectiveness of CDCs using an integrated cohort study in 93 patients with single ventricles, including 41 patients who received CDC infusion and 52 controls. Results: At the time of this study, 36 patients with CDC infusion and 42 controls were alive without cardiac transplantation, with mean follow-up of 9.7±1.2 years. Survival rate did not differ between the 2 groups (log-rank P = 0.351), whereas overall patients treated by CDCs had lower incidents of late failure defined as late death, protein-losing enteropathy, plastic bronchitis, BDG or TCPC take down, disqualified TCPC candidate, Ross classification 3 or 4, or rehospitalization for heart failure (P = 0.048) compared with controls. Adverse events defined as unplanned cardiac operation, arrhythmia, thromboembolic events, cerebral hemorrhage, or tumor formation (P = 0.057) and unplanned catheter intervention (P = 0.094) did not differ between 2 groups. Conclusions: Intracoronary delivery of CDCs in patients with single ventricles did not improve all-cause mortality rate but significantly reduced the incidence of late failure at 8 years of follow-up.

Dual Suture Versus Suture and Plug Closure Devices for Large Bore Access Haemostasis During Percutaneous Access Endovascular Aneurysm Repair.

This study aimed to compare a dual Proglide strategy versus a combination of one Proglide and dual Exoseal for large-bore access closure during percutaneous access endovascular aneurysm repair (pEVAR). We retrospectively analyzed 97 patients who underwent pEVAR at our center between January 2021 and February 2023. The patients were divided into two groups: dual Proglide (P + P) and one Proglide with dual Exoseal (P + E). The primary outcome measures were technical success and access-related vascular complications. Technical success was defined as achieving complete hemostasis without a bailout strategy. Postprocedural follow-up for access-related vascular complications was evaluated at 30 and 60days using computed tomography angiography and ultrasonography. Severity was graded according to the Cardiovascular Interventional Radiological Society of Europe (CIRSE) Classification. Overall, a dual Proglide strategy was used in 46 patients (47.4%) with 65 groins (46.4%), and a combination of one Proglide and dual Exoseal was used in 51 patients (52.6%) with 75 groins (53.6%). The baseline characteristics were similar between the groups. The total technical success rate was 96.4%, and no significant differences were observed (95.4% vs. 97.3%; p = 0.870). Minor bleeding treatable through compression occurred significantly more often in the P group (CIRSE 1, 10.8% vs. 1.3%, p = 0.042). Hemostasis time, procedural time, length of stay in the hospital, closure device failure, and incidence of unplanned intervention did not differ significantly between the groups. A combined Proglide and Exoseal strategy is safe and effective for large-bore access closure during pEVAR and can be considered an alternative. However, it should be supported by larger prospective studies.

“Save the #Talibés”: A State-Led Intervention to Remove Children from the Street in Dakar, Senegal

ABSTRACT Between July 2016 and May 2018, the Senegalese state implemented two phases of a project designed to remove children from the streets of Dakar, targeted at the talibés, or child students of the Qur’an, who beg. Based on qualitative research conducted in Dakar in 2017–2018, this article demonstrates the dynamics behind an uncoordinated and unplanned anti-trafficking intervention. It shows that the contradictions between two different explanations for talibés’ begging led to reward rather than sanctions for those responsible, who are framed variously as child traffickers and as legitimate Qur’anic teachers. It demonstrates the lack of coordination and cooperation among state structures, and between state structures and NGOs, which is then employed by the same actors to explain away the project’s minimal impact. It argues that the project was an example of the Senegalese state trying to adhere to international prescriptions to action to end child trafficking, while avoiding the political wrath of religious leaders domestically. By drawing attention to the distance between global discourse and local implementations, the findings of this article contribute to promoting nuanced policymaking under the Sustainable Development Goal Target 16.2: End abuse, exploitation, trafficking and all forms of violence against and torture of children.

Improving assessment and escalation of threatened haemodialysis access: results of a nursing-led program

BackgroundOptimal vascular access is critical to successful haemodialysis. Acute thrombosis of haemodialysis access often leads to unplanned hospital admissions and interventions to restore patency.Western Health is a large health service in Victoria, Australia. During the period February 2019 to January 2020, the rate of arteriovenous fistula (AVF) and arteriovenous graft (AVG) at Western Health satellite dialysis units was 0.33 episodes per 1000 patient-days, higher than the reported rate in the literature of 0.24 events per 1000 patient-days, and was associated with a cumulative total of 139 days of inpatient stay (2.2 per 1000 patient-days).MethodsThe above results prompted creation of an education and escalation pathway for threatened haemodialysis access, based upon clinical markers of vascular access stenosis or imminent thrombosis assessed by nursing staff in satellite haemodialysis centres.In the period February 2020 to January 2021, the education and escalation pathway was implemented. We assessed referrals via the pathway, rates of AVF/AVG thrombosis and associated hospital length of stay in the following 12-month period (February 2021 to January 2022).ResultsFollowing introduction of the pathway, rates of AVF/AVG thrombosis declined to 0.15 per 1000 patient-days (p = 0.02), associated with a decline in attributable cumulative inpatient stay to 55 days (0.69 per 1000 patient-days).ConclusionsOur program demonstrates that the majority of thrombosed vascular access can be predicted and potentially averted with vigilant and well-practiced routine clinical assessment by trained nursing staff. Our nursing-led education and escalation program successfully identified vascular access at risk of imminent thrombosis, reduced rates of acute thrombosis and associated healthcare costs.Despite these improvements, there are still disparities in outcomes for patients with thrombosed vascular access, with regards to length of stay and requirement for insertion of a temporary central venous catheter (CVC) for urgent dialysis whilst awaiting intervention, and these are areas for further investigation and improvement.

Conventional versus hypofractionated postmastectomy proton radiotherapy in the USA (MC1631): a randomised phase 2 trial

Proton therapy is under investigation in breast cancer as a strategy to reduce radiation exposure to the heart and lungs. So far, studies investigating proton postmastectomy radiotherapy (PMRT) have used conventional fractionation over 25-28 days, but whether hypofractionated proton PMRT is feasible is unclear. We aimed to compare conventional fractionation and hypofractionation in patients with indications for PMRT, including those with immediate breast reconstruction. We did a randomised phase 2 trial (MC1631) at Mayo Clinic in Rochester (MN, USA) and Mayo Clinic in Arizona (Phoenix, AZ, USA) comparing conventional fractionated (50 Gy in 25 fractions of 2 Gy [relative biological effectiveness of 1·1]) and hypofractionated (40·05 Gy in 15 fractions of 2·67 Gy [relative biological effectiveness of 1·1]) proton PMRT. All patients were treated with pencil-beam scanning. Eligibility criteria included age 18 years or older, an Eastern Cooperative Oncology Group performance status of 0-2, and breast cancer resected by mastectomy with or without immediate reconstruction with indications for PMRT. Patients were randomly assigned (1:1) to either conventional fractionation or hypofractionation, with presence of immediate reconstruction (yes vs no) as a stratification factor, using a biased-coin minimisation algorithm. Any patient who received at least one fraction of protocol treatment was evaluable for the primary endpoint and safety analyses. The primary endpoint was 24-month complication rate from the date of first radiotherapy, defined as grade 3 or worse adverse events occurring from 90 days after last radiotherapy or unplanned surgical interventions in patients with immediate reconstruction. The inferiority of hypofractionation would not be ruled out if the upper bound of the one-sided 95% CI for the difference in 24-month complication rate between the two groups was greater than 10%. This trial is registered with ClinicalTrials.gov, NCT02783690, and is closed to accrual. Between June 2, 2016, and Aug 23, 2018, 88 patients were randomly assigned (44 to each group), of whom 82 received protocol treatment (41 in the conventional fractionation group and 41 in the hypofractionation group; median age of 52 years [IQR 44-64], 79 [96%] patients were White, two [2%] were Black or African American, one [1%] was Asian, and 79 [96%] were not of Hispanic ethnicity). As of data cutoff (Jan 30, 2023), the median follow-up was 39·3 months (IQR 37·5-61·2). The median mean heart dose was 0·54 Gy (IQR 0·30-0·72) for the conventional fractionation group and 0·49 Gy (0·25-0·64) for the hypofractionation group. Within 24 months of first radiotherapy, 14 protocol-defined complications occurred in six (15%) patients in the conventional fractionation group and in eight (20%) patients in the hypofractionation group (absolute difference 4·9% [one-sided 95% CI 18·5], p=0·27). The complications in the conventionally fractionated group were contracture (five [12%] of 41 patients]) and fat necrosis (one [2%] patient) requiring surgical intervention. All eight protocol-defined complications in the hypofractionation group were due to infections, three of which were acute infections that required surgical intervention, and five were late infections, four of which required surgical intervention. All 14 complications were in patients with immediate expander or implant-based reconstruction. After a median follow-up of 39·3 months, non-inferiority of the hypofractionation group could not be established. However, given similar tolerability, hypofractionated proton PMRT appears to be worthy of further study in patients with and without immediate reconstruction. The Department of Radiation Oncology, Mayo Clinic, Rochester, MN, the Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA, and the US National Cancer Institute.

Systemic inflammation response index is associated MACE in patients with NSTEMI.

Non-ST segment elevation myocardial infarction (NSTEMI) poses a significant health concern. The systemic inflammation response index (SIRI), an emerging inflammatory marker linked to conditions like stroke and cancer, has shown potential relevance. Inflammation's pivotal role in acute coronary syndromes is well-established, yet its specific association with NSTEMI and SIRI remains unexplored. This study aims to elucidate the correlation between SIRI and major adverse cardiovascular events (MACE) in patients with NSTEMI. A cohort of 935 consecutive NSTEMI patients who underwent percutaneous intervention was recruited. MACE was defined to encompass all-cause death, malignant arrhythmia, and unplanned percutaneous coronary intervention. The systemic inflammation response index, a composite metric involving three distinct inflammatory cell counts, was computed as the product of neutrophil count and monocyte count divided by lymphocyte count. A receiver operator characteristic (ROC) curve analysis was used to define a cut-off level of SIRI to predict MACE. Then, the study population was divided into two groups according to the cut-off SIRI level in ROC curve analysis. The 12-month follow-up results of the patients were recorded retrospectively. The participants exhibited a mean age of 64.12. Notably, the mean SIRI level registered at 1.98 among patients experiencing MACE and 4.97 among others. Through rigorous multivariate logistic regression analysis, SIRI emerged as an independent predictor of MACE. Further analysis via ROC curve yielded a sensitivity of 68% and specificity of 76% for MACE detection, with a SIRI cut-off of 2.3. In the context of NSTEMI, SIRI emerges as a robust independent predictor of MACE. These findings underscore the potential utility of SIRI as a prognostic indicator for adverse cardiovascular events, enhancing our understanding of the disease's pathophysiological mechanisms and potential avenues for improved clinical management.

Planners, blended (in)formality and a public interest of fragments

ABSTRACT Planners need to manage the plurality of everyday living conditions faced by monetary poor communities in South African cities. Here, we develop the concept of blended (in)formality to move beyond binary approaches which classify these communities as having either formal or informal status. Drawing on McFarlane’s (2018, 2021) notion of fragments, we explore how formal planning and spontaneous unplanned urban interventions do not merely co-exist but work together. We formulate a public interest of fragments to demonstrate how communities can benefit from approaches to planning which employ a more fluid understanding of the interactions between the formal and informal.

Single-center Survey of Women Reflecting on Recent Experiences and Preferences of Oral Intake During Labor

(Aust N Z J Obstet Gynaecol 2022;62:643–649) In Australia, increases in unplanned surgical intervention during delivery have caused concern relating to the administration of general anesthesia (GA) and the risks associated with a nonfasted status. There are no recommendations about oral intake during active labor, nor any guidelines associated with patient preferences. Current literature is lacking in evaluation of women who are at increased risk for surgical intervention, or how restricting oral intake affects labor and delivery in these circumstances. This study was designed to assess patient preferences and experiences relating to oral intake during labor to inform future guidelines more effectively. Primary outcomes included advice women received and gastrointestinal symptoms experienced during labor.

Gomco circumcision in the office in patients heavier than 5.5 Kg and/or older than 3 months

Although most pediatric urologists do not perform clamp circumcisions in boys older than 3 months or heavier than 5.5kg, there are no universally accepted guidelines on the optimal patient age or weight. To compare outcomes of office circumcision within and outside these traditional patient parameters. This is a retrospective review of circumcisions performed by a single surgeon from 2019 to 2022. Demographics reviewed include age and weight at time of circumcision, gestational weeks at birth, as well as post-procedure: bleeding, planned and unplanned visits, adhesions/concealment, and interventions related to the circumcision. "Active Bleeding" was defined as bleeding occurring after discharge requiring intervention with pressure, sutures, or cautery. "All Bleeding" included Active Bleeding, and cases where bleeding was controlled at home with pressure, stopped by the time of arrival at clinic or emergency department, and immediate bleeding after circumcision controlled before discharge. During the study period, 773 Gomco circumcisions were performed. A total of 603 patients (78%) had post-procedure evaluation 2 weeks after circumcision. 574 patients (74%) were less than 5.5kg and 199 (26%) over. Only age corrected for gestation was used in the study: 658 (85%) were younger than 3 months and 115 (15%) older. There was no significant difference in Active Bleeding based on weight (p=0.3819) or age (p=0.2798), and no difference in All Bleeding based on weight (p=0.2072). There was a significant difference (p=0.0258) in All Bleeding based on age. There was also a significant difference in unexpected visits based on weight (p=0.0258) and age (p=0.0131). With regards to adhesions, there was no statistical significant differences when comparing weight or age. However, older and heavier boys had significantly more concealment (5% vs <1%). Our study showed Active Bleeding rates 0.5-0.9% higher in the older and heavier group, although the difference did not reach statistical significance. We found a significantly increased rate of unexpected post-procedure visits of around 3.5-4.7% in those patients older than 3 months and heavier than 5.5kg. Also, post -procedure concealment was significantly increased in the older and heavier boys. Modifications of the dressing for high risk groups could reduce the risk of bleeding, and efforts on pre-circumcision education of the families might ameliorate unexpected visits. Exlcuding patients with hidden penis or performing penoscrotal skin tacking at the time of the gomco circumcision could decrease concealment rates in the higher risk patients. Gomco clamp circumcision is safe in patients over 5.5kg and older than 3 months, with a less than 1% higher risk of bleeding, which in the current study was controlled without the need for general anesthesia or transfusions. Broadening the inclusion criteria for office clamp circumcisions could reduce costs and make the procedure available to patients who cannot afford to have the surgery under general anesthesia.

Intravenous Treprostinil in Severe Inoperable Chronic Thromboembolic Pulmonary Hypertension Using Implantable Pumps-Single-Center Experience over More Than a Decade.

The management of chronic thromboembolic pulmonary hypertension has significantly changed over the last decade with the availability of both specific therapies and interventional treatments. In parallel, implantable pumps for intravenous administration of treprostinil have broadened the spectrum of continuous prostanoid infusion. We evaluated the course of 17 consecutive patients with inoperable chronic thromboembolic pulmonary hypertension treated with treprostinil by means of an implantable infusion pump between 2011 and 2023 at our center. Complications associated with the infusion system were rare, leading to 0.4 unplanned surgical interventions during 17,160 patient days. No additional safety signals were detected, and clinical benefits achieved with subcutaneous treprostinil before pump implantation could be maintained in all patients. No catheter-related infections or thromboembolic events were observed. Implantable infusion pumps offer an attractive alternative to subcutaneous treprostinil for patients intolerant to the subcutaneous route, including those with chronic thromboembolic pulmonary hypertension.

Debranching abdominal aortic hybrid surgery for aortic diseases involving the visceral arteries.

Aortic diseases involving branches of the visceral arteries mainly include thoracoabdominal aortic aneurysm (TAAA), aortic dissection (AD) and abdominal aortic aneurysm (AAA). The focus of treatment is to reconstruct the splanchnic arteries and restore blood supply to the organs. Commonly used methods include thoracoabdominal aortic replacement, thoracic endovascular aortic repair and hybrid approaches. Hybrid surgery for aortic disease involving the visceral arteries, consisting of visceral aortic debranching with retrograde revascularization of the celiac trunk and renal arteries and using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients. This study retrospectively analyzed recorded data of patients and contrasted the outcomes with those of a similar group of patients who underwent conventional open repair surgery. Between 2019 and 2022, 72 patients (52 men) with an average age of 61.57 ± 8.66 years (range, 36-79 years) underwent one-stage debranching abdominal aortic hybrid surgery. These patients, the hybrid group, underwent preoperative Computed Tomographic Angiography (CTA) and had been diagnosed with aortic disease (aneurysm or dissection) involving the visceral arteries and were at high risk for open repair. The criteria used to define these patients as high-risk group who are in the need of hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4. In all cases, we accomplished total visceral aortic debranching through a previous visceral artery retrograde revascularization with synthetic grafts (customized Y or four-bifurcated grafts), and aortic endovascular repair with one of two different commercially produced stent grafts (Medtronic® and Lifetech®). In some cases, we chose to connect the renal artery to the artificial vessel with a stent graft (Viabahn) and partly or totally anastomosed. We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 46 patients (36 men) with an average age 54.15 ± 12.12 years (range, 32-76). These 46 patients, the conventional open group, were selected for having had thoracoabdominal aortic replacement between 2019 and 2022. In the hybrid group, 72 visceral bypasses were completed, and endovascular repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 2.78%, and perioperative morbidity was 9.72% (renal insufficiency in 1, unilateral renal infarction in 5, Intestinal ischemia in 1). At 1-month postoperative CTA showed 2 endoleaks, one of which was intervened. At follow-up, there were unplanned reoperation rate of 4.29% and 5 (7.14%) deaths. The remaining patients' grafts were patent at postoperative CTA and no endoleak or stent graft migration had occurred. In the conventional open group, 1 died intraoperatively, 4 died perioperatively, perioperative mortality was 10.87% and complications were respiratory failure in 5, intestinal paralysis/necrosis in 4, renal insufficiency in 17, and paraplegia in 2. At follow-up, 5 (12.20%) patients presented with synthetic grafts hematoma 4 (9.76%) patient died, and 6 (14.63%) patients required unplanned reoperation intervention. Hybrid surgery is technically feasible in selected cases. For aortic diseases involving the visceral arteries, the application of hybrid abdominal aorta debranching can simplify the operation process, decrease the risks of mortality and morbidity in high-risk and high-age populations and decrease the incidence of various complications while achieving ideal early clinical efficacy. However, a larger series is required for valid statistical comparisons, and longer follow-ups are necessary to evaluate the long-term efficacy of hybrid surgery.

Comparative outcomes of bariatric surgery in patients with ESRD on dialysis in the modern era of renal transplantation: analysis using the 2015-2020 MBSAQIP database.

Severe obesity is a relative contraindication for renal transplantation, therefore bariatric surgery is an important option as a pre-kidney transplant weight loss strategy. However, comparative data regarding postoperative outcomes of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with or without ESRD on dialysis are scarce. Patients between 18- and 80-year-old who underwent LSG and RYGB were included. To determine the outcomes of patient who underwent bariatric surgery with ESRD on dialysis, a 1:4 PSM was performed between the patients with ESRD on dialysis and those without renal disease. The PSM analyses in both groups were performed using 20 preoperative characteristics. Then 30-day postoperative outcomes were assessed. The operative time and postoperative-LOS were significantly longer in ESRD patients on dialysis compared to those with no renal disease either for LSG (82.37 ± 40.42 vs. 73.62 ± 38.65; P < 0.001, 2.22 ± 3.01 vs. 1.67 ± 1.90; P < 0.001) or for LRYGB (129.13 ± 63.20 vs. 118.72 ± 54.16; P = 0.002, 2.53 ± 1.74 vs. 2.00 ± 1.68; P < 0.001). In the LSG cohort (2137 vs. 8495 matched cases), patients with ESRD on dialysis showed significant increase in mortality (0.7% vs 0.3%; P = 0.019), unplanned ICU admission (3.1% vs 1.3%; P < 0.001), blood transfusions (2.3% vs 0.8%; P 0.001), readmissions (9.1% vs. 4.0%; P < 0.001), reoperations (3.4% vs. 1.2%; P < 0.001), interventions (2.3% vs. 1.0%; P = 0.006). In the LRYGB group (443 vs. 1769 matched cases), patients with ESRD on dialysis showed a significantly higher need for unplanned ICU admission (3.8% vs. 1.4%; P = 0.027), readmissions (12.4% vs. 6.6%; P = 0.011), and interventions (5.2% vs. 2.0%; P = 0.050). Bariatric surgery is a safe procedure for patients with ESRD on dialysis to help them get a kidney transplant. Even though this group experienced a higher incidence of postoperative complications compared to those without kidney disease, the absolute complication rates are low and not associated with bariatric-specific complications. Therefore, ESRD should not be perceived as contraindications to bariatric surgery.

Post-traumatic stress syndromes following childbirth influenced by birth mode—is an emergency cesarean section worst?

PurposeThe experience of birth is an emotional challenge for women. Traumatic birth experiences can cause psychological stress symptoms up to post-traumatic stress disorders (PTSD), with impact on women’s wellbeing. Primarily unplanned interventions can trigger birth-mode-related traumatization. The aim of the study was to evaluate whether an emergency cesarean section (ECS) is the most traumatizing.MethodsA retrospective case–control study was undertaken. Therefore, data were collected by standardized questionnaires (Impact of Event Scale-Revised and City Birth Trauma Scale) that were sent to women with singleton pregnancies > 34 weeks of gestation who either give birth by ECS (case group, n = 139), unplanned cesarean section (UCS), operative vaginal birth (OVB), or natural birth (NB) (three control groups, n = 139 each). The investigation period was 5 years.ResultsOverall, 126 of 556 (22%) sent questionnaires were returned and could be analyzed (32 ECS, 38 UCS, 36 OVB, and 20 NB). In comparison to other birth modes, women with ECS were associated with a higher degree of traumatization as revealed by statistically significant differences regarding the DSM-5 criteria intrusion and stressor. In addition, women who underwent ECS declared more frequently a demand for professional debriefing compared to other birth modes.DiscussionECS is associated with more post-traumatic stress symptoms compared to other birth modes. Therefore, early interventions are recommended to reduce long-term psychological stress reactions. In addition, outpatient follow-ups by midwives or emotional support programs should be implemented as an integral component of postpartum debriefings.

Duration of antimicrobial treatment for complicated intra-abdominal infections after definitive source control: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

Recent studies have evaluated outcomes associated with duration of antimicrobial treatment for complicated intra-abdominal infections (cIAI). The goal of this guideline was to help clinicians better define appropriate antimicrobial duration in patients who have undergone definitive source control for cIAI. A working group of Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analyses of the available data pertaining to the duration of antibiotics after definitive source control of cIAI in adult patients. Only studies that compared patients treated with short vs. long duration antibiotic regimens were included. The critical outcomes of interest were selected by the group. Noninferiority of short compared with long duration of antimicrobial treatment was defined as an indicator for a potential recommendation in favor of shorter antibiotics course. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and to formulate recommendations. Sixteen studies were included. The short duration ranged from 1 dose to ≤10 days, with an average of 4 days, and the long duration ranged >1 day to 28 days, with an average of 8 days. There were no differences between short and long duration of antibiotics in terms of mortality (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.56-1.44), rate of surgical site infection (OR, 0.88; 95% CI, 0.56-1.38); persistent/recurrent abscess (OR, 0.76; 95% CI, 0.45-1.29); unplanned interventions (OR, 0.53; 95% CI, 0.12-2.26); hospital length of stay (mean difference, -2.62 days; CI, -7.08 to 1.83 days); or readmissions (OR, 0.92; 95% CI, 0.50-1.69). The level of evidence was assessed as very low. The group made a recommendation for shorter (four or less days) versus longer duration (eight or more days) of antimicrobial treatment in adult patients with cIAIs who had definitive source control. Systematic Review and Meta-Analysis; Level III.

Multicenter trans-Atlantic experience with fenestrated-branched endovascular aortic repair of chronic post-dissection thoracoabdominal aortic aneurysms

ObjectiveThis multicenter international study aimed to describe outcomes of fenestrated-branched endovascular aortic repairs (FB-EVAR) in a cohort of patients treated for chronic post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs). MethodsWe reviewed the clinical data of all consecutive patients treated by FB-EVAR for repair of extent I to III PD-TAAAs in 16 centers from the United States and Europe (2008-2021). Data were extracted from institutional prospectively maintained databases and electronic patient records. All patients received off-the-shelf or patient-specific manufactured fenestrated-branched stent grafts. Endpoints were any cause mortality and major adverse events at 30 days, technical success, target artery (TA) patency, freedom from TA instability, minor (endovascular with <12 Fr sheath) and major (open or ≥12 Fr sheath) secondary interventions, patient survival, and freedom from aortic-related mortality (ARM). ResultsA total of 246 patients (76% male; median age, 67 years [interquartile range, 61-73 years]) were treated for extent I (7%), extent II (55%), and extent III (35%) PD-TAAAs by FB-EVAR. The median aneurysm diameter was 65 mm (interquartile range, 59-73 mm). Eighteen patients (7%) were octogenarians, 212 (86%) were American Society of Anesthesiologists class ≥3, and 21 (9%) presented with contained ruptured or symptomatic aneurysms. There were 917 renal-mesenteric vessels targeted by 581 fenestrations (63%) and 336 directional branches (37%), with a mean of 3.7 vessels per patient. Technical success was 96%. Mortality and rate of major adverse events at 30 days was 3% and 28%, including disabling complications such as new onset dialysis in 1%, major stroke in 1%, and permanent paraplegia in 2%. Mean follow-up was 24 months. Kaplan-Meier (KM) estimated patient survival at 3 and 5 years was 79% ± 6% and 65% ± 10%. KM estimated freedom from ARM was 95% ± 3% and 93% ± 5% at the same intervals. Unplanned secondary interventions were needed in 94 patients (38%), including minor procedures in 64 (25%) and major procedures in 30 (12%). There was one conversion to open surgical repair (<1%). KM estimated freedom from any secondary intervention was 44% ± 9% at 5 years. KM estimated primary and secondary TA patency were 93% ± 2% and 96% ± 1% at 5 years, respectively. ConclusionsFB-EVAR for chronic PD-TAAAs was associated with high technical success and a low rate of mortality (3%) and disabling complications at 30 days. Although the procedure is effective in the prevention of ARM, patient survival was low at 5 years (65%), likely due to the significant comorbidities in this cohort of patients. Freedom from secondary interventions at 5 years was 44%, although most procedures were minor. The significant rate of reinterventions highlights the need for continued patient surveillance.

Perioperative nutrition in the setting of pediatric inflammatory bowel disease.

Optimization of nutrition prior to inflammatory bowel disease (IBD)-related surgery could improve outcomes. The aim of this study was to assess the perioperative nutrition status and management of children undergoing intestinal resection for treatment of their IBD. We identified all patients with IBD who underwent primary intestinal resection. We identified malnutrition using established criteria and methods of nutrition provision at various time points (preoperative outpatient evaluation, admission, and postoperative outpatient follow-up) for elective cases (who underwent their procedure at a scheduled admission) and urgent cases (who underwent an unplanned surgical intervention). We also recorded data on postsurgical complications. A total of 84 patients were identified in this single-center study (male sex: 40%, mean age: 14.5 years, Crohn's disease: 65%). Thirty-four patients (40%) had some degree of malnutrition. Prevalence of malnutrition in the urgent and elective cohorts was similar (48% vs 36%; P = 0.37). Of these patients, 29 (34%) were noted to be on some type of nutrition supplementation prior to surgery. Postoperatively, BMI z scores increased (-0.61 vs -0.42; P = 0.0008), but the percentage of patients who were malnourished did not change from preoperative status (40% vs 40%; P = 0.10). Despite this, use of nutrition supplementation was only noted in 15 (17%) patients at postoperative follow-up. Complications were not associated with nutrition status. Utilization of supplemental nutrition decreased postprocedure despite no change in malnutrition prevalence. These findings support the development of a pediatric-specific perioperative nutrition protocol in the setting of IBD-related surgery.

Comparison of Various Joint Decompression Techniques in Septic Arthritis of the Hip in Children: A Systematic Review and Meta-Analysis.

The aim of this review is to conduct an analysis of existing literature on outcomes of application of various methods of joint decompression in management of septic arthritis of the hip in children. A search of literature in PubMed, Embase, and Google Scholar was conducted for identification of studies reporting on the outcomes of intervention for septic arthritis of the hip in children. Of the 17 articles selected, four were comparative studies; two of these were randomized controlled trials while the rest were single arm studies. Statistical difference was observed between the proportion of excellent clinical and radiological outcomes in arthrotomy (90%, 95% confidence interval [CI] 81-98%; 89%, 95% CI 80-98%), arthroscopy (95%, 95% CI 91-100%; 95%, 95% CI 90-99%), and arthrocentesis (98%, 95% CI 97-100%; 99%, 95% CI 97-100%), respectively. The highest overall rate of additional unplanned procedures was observed in the arthrocentesis group (24/207, 11.6%). Patients who underwent arthrocentesis had a statistically greater chance of excellent clinical and radiological outcomes, although the highest level of need for additional unplanned surgical intervention was observed in the arthrocentesis group, followed by the arthroscopy group and the arthrotomy group. Future conduct of a prospective multicentric study focusing on the developed and developing world, along with acquisition of data. such as delay of treatment and severity of disease will enable assessment of the efficacy of one technique over the other by surgeons worldwide.

Impact of transradial versus transfemoral access for preprocedural coronary angiography on TAVR-associated complications.

Vascular injury and bleeding complications remain frequent after transcatheter aortic valve replacement (TAVR). Whether the access-site of preprocedural coronary angiography (CAG) affects TAVR-related complications is not known. The aim of this study was to evaluate the impact of transradial (TRA) versus transfemoral access (TFA) for preprocedural CAG on outcomes in patients undergoing subsequent TAVR. The study cohort included 1002 patients undergoing transfemoral TAVR, of whom 39.4% (395/1002) had undergone radial and 60.6% (607/1002) femoral access for pre-TAVR CAG. The primary endpoint was a composite of 30-day mortality and major vascular complications after TAVR. Key secondary endpoints included VARC-3-defined complications. The primary endpoint occurred less frequently in patients with prior TRA (3.3%) as compared to patients with prior TFA (6.3%, p=0.04), which was mainly driven by significantly lower rates of major vascular complications (0.8% vs 2.5%, p=0.05). Moreover, incidences of periprocedural access-related vascular injury and unplanned endovascular interventions were lower in TRA patients (13.2% vs 18.0%, p=0.05). The rate of major bleeding tended to be lower in the TRA (1.5%) as compared to the TFA group (3.5%) but was not significantly different (p=0.07). Moreover, the rate of life-threatening bleeding was comparable between both groups (0.5% vs 0.8%, p=0.71). Transradial access for preprocedural CAG was associated with significantly lower rates of vascular complications following subsequent TAVR as compared to transfemoral access. However, despite the tendency to lower major bleedings with transradial access, no significant association was detectable between the access-site of coronary angiography and TAVR-related bleeding complications.