Indication For Urgent Surgery Research Articles

The Reoperation, Readmission, and Complication Rates at 30 Days Following Lumbar Decompression for Cauda Equina Syndrome.

Background and objective Cauda equina syndrome (CES) is considered a surgical emergency, and its primary treatment involves decompression of the nerve roots, typically in the form of discectomy or laminectomy. The primary aim of this study was to determine the complication, reoperation, and readmission rates within 30 days of surgical treatment of CES secondary to disc herniation by using the PearlDiver database (PearlDiver Technologies, Colorado Springs, CO). The secondary aim was to assess preoperative risk factors for a higher likelihood of complication occurrence within 30 days of surgery for CES. Methods A total of 524 patients who had undergone lumbar discectomy or laminectomy for CES were identified. The outcome measures were 30-day reoperation rate for revision decompression or lumbar fusion, and 30-day readmissions related to surgery. The patient data collected included medical history and surgical data including the number of levels of discectomy and laminectomy. Results Based on our findings, intraoperative dural tears, valvular heart disease, and fluid and electrolyte abnormalities were significant risk factors for readmission to the hospital within 30 days following surgery for CES. The most common postoperative complications were as follows: visits to the emergency department (63 patients, 12%), surgical site infection (21 patients, 4%), urinary tract infection (14 patients, 3%), and postoperative anemia (11 patients, 2%). Conclusions In the 30-day period following lumbar decompression for cauda equina syndrome, our findings demonstrated an 8% reoperation rate and 17% readmission rate. Although CES is considered an indication for urgent surgery, gaining awareness about reoperation, readmission, and complication rates in the immediate postoperative period may help calibrate expectations and inform medical decision-making.

Predictors of in-hospital mortality in infectious endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Infectious endocarditis has a high rate of in-hospital complications and mortality, ranging between 15 and 30%. Still, there is a paucity of studies on the assessment of short-term prognosis in these patients. Purpose To determine predictors of in-hospital mortality in patients with infective endocarditis. Methods This was a retrospective study that included all patients hospitalized in a single centre with the diagnosis of infective endocarditis, between 2000 and 2020. The relationship between clinical, laboratory and echocardiographic variables and in-hospital mortality was evaluated. Results A total of 161 patients were selected, 65.8% were males, with a mean age of 66.4±16.4 years. The in-hospital mortality rate was 16.8%, occurring on average after 35.0±17.5 days of hospitalization. The average length of stay was 44.5±22.8 days. Age >70 years was associated with higher mortality rate (p=0.021). There were no other significant differences between groups regarding clinical variables and comorbidities. Although not statistically significant, in-hospital mortality group had higher mean ejection fraction (57.2±2.7% vs. 54.6±12.9%). Laboratory parameters associated with mortality included isolation of Staphylococcus (p=0.019) or Enterococcus (p=0.045) in blood cultures. Though the classification of endocarditis (in native vs. prosthesis valve) did not differ between groups, the presence of perivalvular complications on echocardiography (p= 0.042) namely pseudoaneurysm (p=0.003), were more frequent in the group with higher mortality rate. There were 70 patients with indication for urgent surgery, namely for locally uncontrolled infection in 29.2%, heart failure (20.0%) and prevention of embolic events (18.1%). The existence of urgent surgical indication (p=0.009) was associated with higher mortality, and surgery during hospitalization was associated with lower mortality (p=0.011). In a multivariate regression analysis, after adjusting for all the possible confounders, the independent predictors of in-hospital mortality were the previous history of heart failure (HR = 3.29, 95%CI 1.41-7.66), chronic liver disease (HR = 4.33, 95%CI 1.23-15.30) and evolution with septic shock (HR = 6.87, 95%CI 2.89-16.39). Conclusions The present study confirms the high mortality rate of patients with infective endocarditis, highlighting the importance of patient baseline characteristics and comorbidities, as it identified as independent predictors of in-hospital mortality the previous history of heart failure, chronic liver disease and evolution with septic shock.

STRANGULATION PREDICTION FACTORS IN CHILDREN WITH ADHESIVE INTESTINAL OBSTRUCTION

Introduction. Adhesive small bowel obstruction (ASBO) remains one of the leading causes of emergency surgery in children. According to various authors, the incidence of ASBO remains high (in 2-6% of children after abdominal surgery), despite the introduction of minimally invasive technologies and modern means of prevention.
 Objective: To improve the treatment outcomes of patients with ASBO by identifying strangulation prediction factors to determine the indications for urgent surgery.
 Material and methods. We have analyzed the prognostic value of clinical-anamnestic and paraclinical features in 89 children with ASBO which may be pathogenetically associated with the presence of strangulation. 75.3% of them (67 patients) had obstructive ASBO nature, and 24.7% (22) had strangulation. The analysis was performed using conjugation tables and Pearson's χ2 criteria. The connection was considered reliable at p <0,05.
 Results. We have determined 8 signs which demonstrated the presence of a statistically significant connection with the strangulation nature of obstruction, among which the greatest prognostic value (p≤0.001) had positive peritoneal signs (χ2 = 15.256), free fluid in the abdominal cavity during ultrasound monitoring of the pelvis (χ2 = 13.777) and in the form of inter-loop effusion (χ2 = 6.473). From laboratory data it is necessary to pay attention to the existence of a hyperleukocytosis (52,6%). These signs, identified as a result of the study, can be obtained quickly and easily at the initial examination of a patient and allow to effectively assess the likelihood of strangulation obstruction and, accordingly, to assist in making a clinical decision.
 Conclusion. For timely diagnosis of irreversible intestinal wall changes at strangulation obstruction, ultrasound examination of abdominal organs should be performed immediately upon treatment or hospitalization of a child with ASBO to avoid intestinal damage due to strangulation and development of peritonitis. The presence of 2 or more of the identified prognostic factors (89.5%) in children with ASBO means a "strong" connection with the presence of strangulation (PCC = 0.627), which can be considered as an indication for the urgent surgical treatment.

Early corset reclination of uncomplicated type А3 comminuted vertebral fractures in the thoracolumbar spine

Objective. To analyze the results of staged preoperative correction of uncomplicated comminuted fractures in the thoracolumbar spine.Material and Methods. Retrospective study included data from 51 patients (33 men and 18 women) 17–35 years old with type A3 spinal injuries without urgent indications for surgery. In preparation for a possible operation, patients received a corset treatment with reclination pneumopelot for 2–3 days.Results. The results were evaluated based on clinical, radiological and CT data. The result after reclination corset treatment was considered good if a restoration of the vertebral height was achieved with its residual deficit of less than 10 % or local wedge shape not more than 10°; satisfactory – with a residual decrease in vertebral body height from 10 to 30 % or in kyphotic deformity from 10 to 20°; and unsatisfactory – with a decrease in body height of more than 30 %, and in kyphotic deformity of more than 20°. With an average decrease in the height of the fractured vertebral body before surgery by 45 % and the local kyphosis magnitude of 27.0° ± 5.5°, the staged reclination provided complete correction of kyphosis in all cases and restoration of the height of the compressed vertebra to a residual deficit of less than 10 % in 78 % of cases. Neurological disorders were not noted.Conclusion. In case of incomplete burst vertebral fractures not complicated by compression of the spinal cord, the method of early (in the first 7 days after the injury) corset treatment with staged fracture reclination by a pneumatic chamber can be effectively used to eliminate local kyphotic deformity and restore the height of fractured vertebra.

Acute upper gastrointestinal bleeding: A review

Abstract Gastrointestinal haemorrhage is potentially life threatening. Resuscitation, clinically diagnosing and treating the underlying problem are the principles of management. As most gastrointestinal haemorrhage cease spontaneously, there is greater importance in non- operative intervention. Radio-embolisation is a growing useful adjunct in available armamentarium for non-operative management. The definitive management of upper GI hemorrhage is indicated by the overall risk of re-bleeding and morbidity (Rockall risk score). Failure to respond to endoscopic and medical management is an indication for urgent surgery. New endoscopic techniques and radiological embolisation have decreased the role of surgery in management, but collaboration between the endoscopist and the surgeon remains.

Arteriovenous malformations of the brain in children: treatment results for 376 patients

Cerebral arteriovenous malformations (AVM) are increasingly detected in children. To estimate the risk of hemorrhage in children with AVM before and after treatment and evaluate the outcomes of various methods of AVM management in children. This study included 376 patients with various cerebral AVM under the age of 18 years. There were 273 patients with intracranial hemorrhage (72.6%). Recurrent hemorrhages within the first month were registered in 1.1% of patients with angiomatous AVM prior to treatment and in 15.4% of patients with fistulous AVM. Microsurgical resection of AVM was performed in 135 (35.9%) patients. Total resection was achieved in 97.8% of cases. There were no mortality after microsurgical procedures. Endovascular treatment was applied in 79 (21%) patients. Total embolization was achieved in 29.1% of patients. One patient (1.3%) died after endovascular procedure. Radiosurgery was performed in 140 (37.2%) patients with total obliteration after a single fraction in 64.4% of patients. Favorable long-term outcomes (GOS grades V-IV) were achieved in 89.6% of patients with available follow-up data (n=182). Recurrent hemorrhages were registered in 6% of patients (3.3% after radiosurgery, 2.7% after endovascular treatment). One patient with recurrent hemorrhage died after radiosurgery. Early relapses of hemorrhage are not characteristic for children with cerebral AVM. Therefore, there are no indications for urgent surgery except for cases of intracerebral hematoma. In children, microsurgical treatment is preferred for angiomatous AVM, endovascular treatment - for fistulous AVM. Radiosurgery also ensures favorable outcomes. However, it is unreasonable to postpone AVM radiosurgical treatment in children with increased risk of recurrent hemorrhage considering relatively long period of post-radiation obliteration of AVM.

VASCULAR ANOMALIES IN NEWBORNS: CLINICAL PRESENTATION, COMPLICATIONS, AND PECULIARITIES OF THERAPY

The aim: To analyze cases of vascular anomalies in newborns retrospectively to study their main clinical signs and to determine indications for urgent treatment. Materials and methods: A retrospective review of 281 pediatric vascular anomalies diagnosed between 2011 and 2019 was performed. The results of clinical examination, prenatal history, laboratory, sonography, and radiological data were evaluated. Results: Clinical manifestations in the newborn period documented in 170 (60.5%) patients, anomalies were visualized prenatally in 8.9% cases. Five newborns with head and neck LMs required urgent treatment, which amounted 7.9% of all newborns with LMs. The indication for urgent surgery was acute respiratory failure. Partial malformation resection with tracheostomy was performed to those patients, along with intraoperative injection of sclerotherapeutic agents and argon coagulation of residual malformation tissues. EXIT procedure was performed in one case. No correlation (p=0.2) was found between the number of skin lesions and the severity of liver lesions in children with multifocal hepatic hemangiomas, congestive cardiac failure suddenly occurs in one patient in the third week of life. Two newborns with diffuse hepatic hamangioma were manifested right after the birth with clinical signs of liver failure, hypothyreosis, and cardiac failure. Short courses of corticosteroids performed in 7 patients with KHE and Kasabach-Merritte fenomemn for thrombocytopenia correction. Conclusions: Clinical signs of vascular anomalies in neonatal period were seen in 57.5% children with vascular anomalies, and only 2.9% of them required treatment. Treatment itself is advantageous only in cases when life-threatening complications develop, such as airways obstruction, cardiac and/or liver failure, thrombocytopenia.

Parenteral Nutrition Instead of Early Reoperation in the Management of Early Postoperative Small Bowel Obstruction

BackgroundIn majority of patients, early postoperative small bowel obstruction (EPSBO) resolves with nasogastric decompression and bowel rest alone, while in some patients, symptoms persist without urgent indications for surgery. The purpose of this study was the evaluation of home parenteral nutrition (HPN) instead of elective surgery as an initial approach to persistent EPSBO. MethodsPatients developing EPSBO prescribed HPN without reoperation within 6 weeks after index intestinal surgery were identified from an institutional HPN registry and retrospectively compared with patients undergoing reoperation for EPSBO within the same time period. ResultsThirty-four patients for the HPN group and 27 patients in elective reoperative (REOP) group met the inclusion criteria. In the HPN group, mean interval between surgery and PN initiation was 11 days. HPN duration ranged from 17 to 244 days with a median of 60 days. Thirty-one patients (91%) successfully recovered bowel function and resumed enteral nutrition without reoperation, while 3 patients required reoperation > 6 weeks after index surgery due to HPN failure. In the REOP group, mean interval between index surgery and reoperation was 17 days. At reoperation, 12 patients required bowel resection, 5 having incidental enterotomies, and 3 required new stoma creation. Postoperatively, 2 patients developed enterocutaneous fistulas, 1 experienced an anastomotic leak, and another had fascial dehiscence. ConclusionHPN is a safe alternative to elective surgery in clinically stable patients with persistent EPSBO. This approach avoids hazardous reoperation during the recovery phase when adhesions are at their worst.

Infective endocarditis: innovations in the management of an old disease.

The annual incidence of infective endocarditis (IE) is estimated to be between 15 and 80 cases per million persons in population-based studies. The incidence of IE is markedly increased in patients with valve prostheses (>4 per 1,000) or with prior IE (>10 per 1,000). The interaction between platelets, microorganisms and diseased valvular endothelium is the cause of vegetations and valvular or perivalvular tissue destruction. Owing to its complexity, the diagnosis of IE is facilitated by the use of the standardized Duke-Li classification, which combines two major criteria (microbiology and imaging) with five minor criteria. However, the sensitivity of the Duke-Li classification is suboptimal, particularly in prosthetic IE, and can be improved by the use of PET or radiolabelled leukocyte scintigraphy. Prolonged antibiotic therapy is mandatory. Indications for surgery during acute IE depend on the presence of haemodynamic, septic and embolic complications. The most urgent indications for surgery are related to heart failure. Inthe past decade, the prevention of IE has been reoriented, with indications for antibiotic prophylaxis now limited to patients at high risk of IE undergoing dental procedures. Guidelines now emphasize the importance of nonspecific oral and cutaneous hygiene in individual patients and during health-care procedures.

Management of pre-existing anticoagulation for timely treatment of proximal femoral fractures

Proximal femoral fractures are urgent indications for surgery. In cases of delayed surgical treatment more than 48 h after hospital admittance, increased rates of general complications, local complications and mortality have been proven. Since 2015, the quality target for the external quality assurance by order of the Federal Joint Committee (G-BA) is surgical treatment within 24 h after hospital admittance for osteosynthesis and within 48 h for joint replacement. The foundations for these time intervals are the S2e guidelines for the treatment of femoral neck fractures of adults from the German Society of Trauma Surgery (DGU) and the Austrian Society of Trauma Surgery (ÖGU) and several other international guidelines. The distinction of the temporal specifications between osteosynthesis and joint replacement in Germany is unusual in comparison with other countries. For 15% of each group of patients aprolonged preoperative preparation is accepted. In the structured dialog within the external quality management anticoagulants are quoted as the most frequent reason for delayed surgery. The present review provides away to achieve compliance with statutory provisions, to minimize the risks of both bleeding and thromboembolism and to achieve surgical treatment of proximal femoral fractures within the agreed time limit.

Diagnosis and Management of Acute Diverticulitis

Diverticulitis is the cause of 300,000 inpatient admissions in the United States each year. Surgical evaluation and treatment are commonly required for the treatment of diverticulitis. This chapter discusses the diagnosis, triage, and treatment of acute diverticulitis. Medical treatment, as well as the indications for surgical treatment for diverticulitis, is discussed. Current controversies, including the need for antibiotics for a patient with acute uncomplicated diverticulitis, necessity of colonoscopy after resolution of an acute episode, and indications for urgent surgery, are reviewed. This review contains 10 figures, 3 tables, and 67 references. keywords: acute diverticulitis, colonic fistula, complicated diverticulitis, diverticular abscess, diverticular disease, diverticulitis, diverticulosis, perforated diverticulitis, uncomplicated diverticulitis

Comparative Study of a Single-Incision Laparoscopic and a Conventional Laparoscopic Appendectomy for the Treatment of Acute Appendicitis in Children

Appendicitis is the most common indication for urgent surgery in children. Single-incision laparoscopic surgery (SILS) has further improved surgical outcomes. In this study we compared SILS and conventional in terms of peroperative difficulty and outcomes. A retrospective chart review was performed interesting all patients operated for acute appendicitis in the department of pediatric surgery Hedi Chaker hospital and department of surgery Habib Borguiba hospital between January 2006 and December 2016. Among the total of 181 patients, LA and SILS were performed respectively on 51 (28.2%) and 137 patients (71.8%). In 41.9% of patients of conventional LA it was a complicated appendicitis and in 29.8% of SILS group it was a complicated appendicitis (p=0.22). The mean operative time was 63.7 min for the conventional LA group and 71.79 min for the SILS group, it was not statistically significant (p=0.046). Conversion was made in 13.7% of patients in the conventional LA and in 5.8% in patients with SILS (p=0.14). The median length of hospital stay was for the conventional LA group 3.5 days and for SILS group 2.3 days (p=0.04). The current study found that SILS provided comparable surgical outcomes to conventional LA and did not result in increased postoperative complication rates.

Congenital coronary artery anomalies

Abstract Congenital coronary artery anomalies are abnormalities in the origin, course or structure of these arteries, and their incidence varies from 0.2% to 5.6%. Although the majority of anomalies are asymptomatic, they are the second most common cause of sudden cardiac death in young athletes. The aim of this study is to highlight the main anomalies with hemodynamic significance, particularly anomalous aortic origin of coronary arteries and anomalous left coronary artery from the pulmonary artery. Anomalous aortic origins of coronary arteries account for 14–17% of all sudden cardiac deaths that unexpectedly occur in healthy children or young athletes during or immediately after physical exercise. The mechanism responsible for the compression/occlusion of the coronary artery originating from the opposite sinus is still unclear and several mechanisms have been proposed. The clinical presentation of these patients varies and physical examination is normal in most cases. Transthoracic echocardiography is the most commonly used test for diagnosis. The treatment, management and follow-up of these patients are the subject of debate. The anomalous origin of the left coronary artery arising from the pulmonary artery is an even rarer condition and, without corrective surgery, most patients die within the first year of life. Echocardiography is also the method of choice to confirm this condition. The diagnosis of this anomaly in a seriously ill child is an indication for urgent surgery. Due to the hemodynamic abnormalities caused by these abnormalities, early diagnosis and treatment are important.

Mortality and morbidity of patients on the waiting list for coronary artery bypass graft surgery.

The public health care system in Brazil has extensive waiting lists of patients requiring complex operations such as coronary artery bypass grafting (CABG). The purpose of this study was to identify the mortality and morbidity rates of the patients awaiting CABG and identify predictors of adverse events and their association with perioperative outcomes. We conducted a retrospective analysis of outpatient medical records of patients referred for this elective procedure in Rio de Janeiro, Brazil. Excluded from the study were records of patients with any of the following: an indication for urgent surgery, unstable angina or concomitant surgical valvular disease or subsequent transfer to clinical or percutaneous therapy. A total of 274 patients were identified and met the inclusion criteria, with a median waiting time for an operation of 142.7 days. While waiting for CABG surgery, 31 (11.3%) patients died of any cause and 42 (15.3%) patients had a serious cardiac event (death, myocardial infarction or unstable angina). Of the 22 (8%) incidents of acute myocardial infarction, 8 (2.9%) were non-fatal and 14 (5.1%) were fatal. There was a greater risk of death awaiting CABG surgery in patients with a left ventricular ejection fraction below 45% (hazard ratio = 2.33, 95% confidence interval 1.02-5.32; P = 0.039). The operative mortality rate was 5.8%. Although there was no evidence of worse perioperative outcomes in patients with prolonged waiting times for an operation, there was an association between waiting more than 16 weeks for an operation and death while on the list. Extensive waiting periods for CABG contribute to higher mortality and morbidity rates, especially in patients with left ventricular dysfunction.

A representative assessment of the management of open fractures of the lower limb within UK orthoplastic centres: A two-centre audit of compliance with national standards

BackgroundOpen fractures of the lower limb represent a complex and varied array of injuries. The BOAST 4 document produced by BAPRAS and the BOA provides standards on how to manage these patients, and NICE have recently produced additional guidance. We aimed to assess concordance with these standards in a large cohort representative of UK orthoplastic centres. MethodsPatients admitted to the orthoplastic units at Norfolk and Norwich University Hospital and Royal Stoke University Hospital with open lower limb fractures between 2009 and 2014 were included. Data was gathered from notes and endpoints based on the BOAST 4 document. ResultsIn total, 84 patients were included across the two sites, with 83 having their initial debridement within 24h (98.8%). Forty-two patients had a documented out-of-hours initial surgery. Of these, 10 (23.8%) had an indication for urgent surgery. This pattern was consistent across both hospitals. A plastic surgeon was present at 33.3% of initial operations. Of 78 patients receiving definitive soft tissue cover, 56.4% had cover within 72h and 78.2% within 7days. Main reasons for missing these targets were transfer from other hospitals, plastic surgeons not present at initial operation and intervening critical illness. ConclusionsThis study has identified key areas for improving compliance with the national BOAST 4 and NICE standards. Out-of-hours operating is occurring unnecessarily and time targets are being missed. The development of dedicated referral pathways and a true orthoplastic approach are required to improve the management of this complex set of injuries.

The Use of Secondary Prognostic Parameters when Malignancy of Undefined Primary Origin is Present in Spinal Metastases

Introduction Accurate prognostication is not feasible when the primary malignancy is unknown. Patients who harbor spinal metastases with malignancy of undefined primary origin are common in the clinical scenario of installed paraplegia within 24 hours or rapid progressive paraparesis. Acute spinal nervous tissue compression is an indication for urgent surgery and should be performed within 24 hours of hospitalization. In this urgent clinical situation, time-consuming neoplastic disease staging may not be feasible. An estimated 3-month post-operative survival period seems reasonable for the decision-making process regarding whether surgery should be performed. When the primary malignancy site is unknown, secondary parameters are used to estimate patient survival. Special patient care dependency, spinal cord tumor compression, walking impairment, urgent surgery, and malignancy of undefined primary origin can be used to estimate survival and can act as secondary prognostic parameters of survival. The objective of this study is to identify pre-operative prognostic parameters for survival in patients with spinal metastasis when malignancy of undefined primary origin is present. Material and Methods This study was a retrospective chart review of patients who underwent surgery for spinal epidural neoplastic metastases between February 1997 and January 2011. Inclusion criteria: Knowledge of the post-operative survival period. Five pre-operative prognostic parameters for patient survival where identified: Special care dependency (Karnofsky Performance Score ≧30 points); Spinal cord tumor compression (MRI/TAC spinal imaging); Walking impairment ( ASIA Scale A & B); Urgent surgery; Malignancy of undefined primary origin. Statistical analysis compared patients with the selected five prognostic parameters for survival to those with one to four of these prognostic parameters. The Kaplan–Meier method was used to estimate the post-operative survival and the log-rank test was used for statistical inference. Results A total of 52 patients who underwent 52 surgical procedures were identified. The mean age at the time of spinal surgery was 53.92 years (standard deviation 19.09). Malignancy of undefined primary origin was present in 36 (69.23%) of the patients in the preoperative period. The overall median survival after surgery was 70 days (95% CI: 49.97–90.02) and post-operative mortality occurred within 6 months in 38 (73.07%) patients. The median post-operative survival for the 16 (30.77%) patients harboring the selected five prognostic parameters to estimate survival was 22 days (95% CI: 4.36–39.64) and for the other 36 (69.23%) patients with one to four of the prognostic parameters, 72 days (95% CI: 57.30–86.70). The mean post-operative survival for the same 16 (30.77%) patients harboring the selected five prognostic parameters to estimate survival was 109.75 days (95% CI: 107.49–251.27) and for the other same 36 (69.23%) patients with one to four of the prognostic parameters, 210.33 days (95% CI: 118.46–302.20). Statistical inference for the five analyzed prognostic parameters was p-value = 0.123 Conclusion Patient special care dependency, spinal cord tumor compression, walking impairment, urgent surgery and malignancy of undefined primary origin are useful as secondary prognostic parameters for patient survival. A 2- to 3-month post-operative survival period justified surgical treatment in this study.

The Prognostic Factor of Malignancy of Undefined Primary Origin in Spinal Metastases

Introduction Malignancy of undefined primary origin is metastatic malignancy identified on the basis of a limited number of tests, without an obvious primary site, before comprehensive investigation.2 Patients who harbor spinal epidural neoplastic metastases with malignancy of undefined primary origin are common in the clinical scenario of installed paraplegia within 24 hours or rapid progressive paraparesis. Acute spinal nervous tissue compression is an indication for urgent surgery and should be performed within 24 hours of hospitalization. In this urgent clinical situation, time-consuming neoplastic disease staging may not be feasible. An estimated 3-month postoperative survival period seems reasonable for the decision-making process regarding whether surgery should be performed. The physician may reason that if the knowledge of the primary tumor site is not a prognostic factor for survival in preoperative urgent surgery for spinal epidural neoplastic metastases, then surgery must not be postponed. The objective of this study is to compare the postoperative survival between patients with defined and undefined malignancy of primary origin as a prognostic factor for survival in spinal metastases. Material and Methods This study was a retrospective chart review of patients who underwent surgery for spinal epidural neoplastic metastases between February 1997 and January 2011. The inclusion criteria were as follows: known postoperative survival period, a Karnofsky performance score equal to or greater than 30 points, and a postoperative neoplastic metastasis histological type. The Kaplan–Meier method was used to estimate the postoperative survival and the log-rank test was used for statistical inference. Results A total of 52 patients who underwent 52 surgical procedures were identified. The mean age at the time of spinal surgery was 53.92 years (standard deviation 19.09). The median survival after surgery was 70 days (95% CI: 49.97–90.02) and postoperative mortality occurred within 6 months in 38 patients (73.07%). The primary neoplasm site and histological type were unknown in 36 (69.23%) of the patients in the preoperative period. The following primary tumor types were identified after the surgery: myeloma (8 patients), lung carcinoma (6), sarcoma (5), prostate carcinoma (5), lymphoma (4), undifferentiated carcinoma (4), thyroid carcinoma (1), pineal germinoma (1), gastric adenoma (1), and kidney blastoma (1). Cancer type was the strongest overall survival indicator in this study ( p = 0.023). The median postoperative survival for the 16 patients (30.77%) with known preoperative primary tumors was 59 days (95% CI: 11.96–106.04) and it was 72 days (95% CI: 51.45–92.54) for the 36 patients (69.23%) with unknown tumors. The statistical inference was p = 0.719 and statistically insignificant for postoperative survival between the known and unknown primary tumor site. The median postoperative survival in patients with elective surgery was 76 days (95% CI: 53.571–98.429) and for urgent surgery was 45 days (95% CI: 3.553–86.447). The statistical inference was p = 0.124 for postoperative survival between the elective and urgent surgery patients. Conclusion Undefined malignancy of primary origin is not a prognostic factor for survival in patients who harbor spinal epidural neoplastic metastases when compared with those with a defined malignancy of primary origin in this research study. References Daniel JW. Survival prognostic parameters in patients with spinal column epidural metastatic neoplasms [PhD thesis]. São Paulo, SP, Brazil: Santa Casa de São Paulo, Faculty of Medical Sciences; 2013 National Institute for Health and Clinical Excellence. 2010. Metastatic malignant disease of unknown primary origin. London: NICE clinical guideline. Available at: https://www.nice.org.uk/search?q=Metastatic+malignant+disease+of+unknown+primary+origin. Accessed September 20, 2014

Supracondylar humeral fractures with isolated anterior interosseous nerve injuries: is urgent treatment necessary?

It is unclear if pediatric patients with a supracondylar humeral fracture and isolated anterior interossous nerve injury require urgent treatment. A retrospective, multicenter study of 4409 patients with operatively treated supracondylar humeral fractures was conducted. Exclusion criteria were additional nerve injuries other than the anterior interosseous nerve, any sensory changes, pulselessness, ipsilateral forearm fractures, open fractures, less than two months of follow-up, or pathological fractures. Thirty-five of 4409 patients met inclusion criteria. The average time to surgery was 14.6 hours (range, two to thirty-six hours). No patient developed compartment syndrome. There was no significant difference in time to return of anterior interosseous nerve function relative to the time to surgical reduction and fixation (p = 0.668). A complete return of anterior interosseous nerve function occurred in all patients with an average time of forty-nine days (range, two to 224 days). Ninety percent of patients recovered anterior interosseous nerve function by 149 days. To our knowledge, this is the largest series to date of supracondylar humeral fractures with anterior interosseous nerve injuries. There is no evidence that a supracondylar humeral fracture with an isolated anterior interosseous nerve injury requires urgent treatment. A delay in treatment up to twenty-four hours was not associated with an increased time of nerve recovery or other complications. This series excluded patients with sensory nerve injuries, pulselessness, and ipsilateral forearm fractures, which all may require urgent surgery. Barring other clinical indications for urgent treatment of a supracondylar humeral fracture, an isolated anterior interosseous nerve injury (no sensory changes) may not by itself be an indication for urgent surgery. The anterior interosseous nerve injuries in this series showed complete recovery at a mean time of forty-nine days.

Fusion of cardiac computed tomography angiography and 18F-fluorodesoxyglucose positron emission tomography for the detection of complicated prosthetic heart valve endocarditis

Purpose: PHV endocarditis is complicated by peri-annular extension (abscesses/mycotic aneurysms) in 50% of patients and has an in-hospital mortality of 30%. Transthoracic and Transesophageal Echocardiography (TTE and TEE) may fail to recognize peri-annular extensions, although this is an indication for urgent surgery. Therefore Computed Tomography Angiography (CTA) fused with 18F-Fluorodesoxyglucose Positron Emission Tomography (FDG-PET) may be of additional value. Methods: PHV patients that underwent FDG-PET were selected from the hospital database. CTA images were fused with FDG-PET images and the Standardized Uptake Value (SUV) ratio was measured. Imaging findings were compared to the reference standard: surgical inspection. Results: Eleven PHV endocarditis cases and four normal functioning PHV controls were identified. All cases and controls underwent TTE, TEE and CTA. In 11/11 (100%) endocarditis cases, imaging by fused FDG-PET and CTA detected high FDG uptake around the PHV. Surgical inspection confirmed peri-annular extension of endocarditis in all cases. Controls (n=4) were all free of significant FDG uptake. SUV ratios around the PHV ring were significantly (p=0.001) higher in endocarditis cases; 4.6 (IQR 3.8-5.1) compared to controls; 2.0 (IQR 1.7-2.1). SUV ratios around the PHV ring in cases were all above 2.6, whereas all controls had SUV ratio's below 2.3. ![Figure][1] A:TEE, B:CTA, C:Fused CTA and FDG-PET Conclusion: Fused cardiac FDG-PET and CTA imaging is a promising tool to correctly diagnose PHV endocarditis. SUV ratios may be used to discriminate PHV endocarditis with peri-annular extension from non-infected PHVs or PHVs endocarditis without peri-annular extension. Fused FDG-PET and CTA may be considered in patients with a high suspicion of PHV endocarditis but inconclusive routine work-up. [1]: pending:yes

Reply to Acar Early surgery in active valve endocarditis

We thank Dr Acar for his thoughtful comments [1] on our recently published work focusing on mitral valve (MV) repair for active infective endocarditis (IE) [2]. Dr Acar has suggested that an early surgical approach could blind the potential eradication successes ofmedical treatment aloneandbelieves that repair is easier during the healed phase of IE than during the active one. Effectively, our current approach is to operate on patients with active IE very early during the course of the disease, even after only a few days of antibiotic therapy. Herein, we insist on the fact that if we had operated on the patient earlier compared to our historical controls, we have not broadened the classical indications for surgical treatment. According to the recently published ACC/AHA guidelines [3], the level of evidence for surgical exploration presented by our study population was class I in 43 patients, class IIA in 18 and class IIB in 2 patients, respectively. During the study period, a total of 127 patients were treated for native MV IE in our institution. Eighty-one (64%) were operated on during the active phase (63 repairs = our study cohort [2] and 18 replacement) and 46 (36%) received medical treatment only. Comparing this with the recent study referenced by Dr Acar [4], and taking account of the fact that the later study combined aortic and mitral native IE, it seems that we do not over treat patients as the rate of surgery was lower in our experience (64% vs 71%). Beside commonly accepted indications for urgent surgery, we applied early surgery in other indications for the following reasons: Firstly, as a preventative tool for any new complicating events that may impair patients prognosis. We agree with Dr Acar that themajority of complications occur before diagnosis and that the risk of a newcomplicationdecreaseswithmedical therapy. However, the study cited here above reported a persistent risk of complication even after initiation of medical therapy [4]. The authors showed that almost half of the heart failures and septic shocks, and two thirds of the cardiovascular collapses occurred during medical treatment. Secondly, as a tool to improve the reparability rate of the valve. Indeed, since repair has proven to be superior to replacement in degenerative disease, we believe that surgeons should be at ease with the reconstructive approach in the setting of more difficult situations as well. In IE, destruction of the mitral valve is progressive but more rapid than in any other non-infectious disease. Since valve repair is highly dependant of the quantity and quality of residual tissues, early intervention is of interest for saving more tissues. In our opinion, fresh and bulky lesions are not too difficult to manage and at this early stage lesion margins are well circumscribed allowing easy resection and tissue preservation. Furthermore, annular abscesses, present in one third of the patients [2,4], are currently considered as a formal indication [3] because of their morbidity and the relative inefficacy of antibiotics to eradicate them [5]. Therefore, we found no reason to delay surgery when diagnostics of an abscess is suggested. In conclusion, since a prospective randomised trial on medical versus surgical approach for NVE in unlikely to happen, no evidence will ever be undisputable, and clinician decision-making will rely on available literature. Our study shows that in an experienced centre early surgery seems to be safe and for this reason may be performed in selected patients presenting recommended indications. Obviously, other studies are necessary to define the place of early surgery in the wide spectrum of IE disease.