Vascular Compromise Research Articles

O193: Drains versus No Drain in Thyroid Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Abstract Introduction Thyroid surgery does not come without its risks of complications of post-operative haemorrhage, haematoma and seroma, for which drains may be used. Placement of a drain may prevent these complications, which may be life-threatening due to vascular compromise and airway compression. Objective This study aims to evaluate the outcomes and complications in patients undergoing thyroid surgery with a drain and without a drain. Methods Systematic review of all studies up to October 2023. These studies were identified from all major databases including MEDLINE, Cochrane (1960–2023), and EMBASE (1991–2023). All studies reporting a comparison between drain and no drain thyroid surgery were searched; all studies were included. Post-operative complications and outcomes were recorded and analysed. Results 35 studies with 4089 patients contributed to the summative outcome measures. The no drain group showed a statistically significant superiority compared to the drain group when it came to infection rates (p=0.0001), re-operation rates (p=0.05), pain score (p<0.00001) and length of stay (p<0.00001). There was no statistical difference for haematoma (p=0.52), haemorrhage (p=0.39) or seroma rates (p=0.38). Conclusion There is a superiority in postoperative outcomes and reduced complications in favour of patients without a drain compared to patients with a drain following thyroid surgery. A large number of studies with a large patient population were included; further studies are required to assess the individual suitable indications for a drain in thyroid surgery.

The aetiology of fracture and nonunion in the hook of the hamate.

Fractures of the hook of the hamate are traditionally thought to be caused by direct trauma. A review of the anatomy and function of the hamate hook suggests that fracture is more likely as a result of a fatigue response that develops in the hook from repetitive load applied by the adjacent deep flexor tendons. Additional vascular compromise, from direct pressure of the tendons on critical local vessels, reduces blood flow leading to both mechanical and vascular effects that create pathological osseous change and weakening. These changes are likely to predispose to stress fracture and nonunion in repetitive gripping activities and are consistent with radiological findings.

Open Exploration and Reduction of Paediatric Supracondylar Humerus Fracture with Pink, Pulseless Hand in Resource-Limited Settings.

Background: Supracondylar humerus fractures (SHFs) are common paediatric injuries, with high risk of vascular compromise. Some patients present with a 'pink, pulseless hand', caused by occlusion of brachial artery flow but with collateral circulation preserving distal perfusion. Management of these patients remains controversial, especially when resources may be limited for prolonged hospitalisation and serial monitoring by skilled staff. The aim of this study is to present the intraoperative findings, surgical procedures done and outcomes at 6 weeks for patients with paediatric supracondylar fractures with a pink pulseless hand. Methods: We retrospectively identified 13 patients who presented to a public hospital between January 2019 and May 2023 with a displaced SHF and pink, pulseless hand. All patients underwent an open reduction with an anterior approach allowing for exploration, protection and repair of neurovascular structures. Distal flow was restored in the brachial artery either with topical lidocaine application, thrombectomy or artery reconstruction. Results: Out of 13 patients, all had intact median nerves and 10 had intact arteries (69%), of which seven were interposed at the fracture site and four were in vasospasm. Of the three patients with true arterial injury (23%), two had a crushed artery and one had thrombosis of the artery. Peripheral pulses were restored within an hour of fracture open reduction in all patients. At final follow-up, a mean 6 weeks postoperatively, all patients had recovered without neurovascular deficit, compartment syndrome or Volkmann ischemic contracture. Conclusions: In resource-limited settings, we recommend performing open exploration and reduction for patients with SHFs with pink, pulseless hand. This approach prevents iatrogenic neurovascular injury during closed reduction attempts, allows for immediate repair of a brachial artery injury and avoids unnecessary hospitalisation and serial monitoring. Level of Evidence: Level IV (Therapeutic).

Association Between Augmentation Index and Total Sleep Time in Night Shift Workers.

Augmentation index and pulse wave velocity are markers of vascular compromise and independent predictors of cardiovascular risk and mortality. While the link between shift work and heightened cardiovascular risk is established, the intricate genesis of early cardiovascular outcomes in shift workers remains incompletely understood. However, there is evidence that sleep duration plays a role in this regard. Here we evaluate the association of total sleep time with pulse wave velocity, augmentation index, and central blood pressure in night shift workers. This study cross-sectionally evaluated the association of total sleep time evaluated by 10-day monitoring actigraphy with augmentation index, pulse wave velocity, and brachial and central blood pressure evaluated by oscillometry in nursing professionals, 63 shift workers (89% women; age = 45.0 ± 10.5 years), and 17 (100% women; age = 41.8 ± 15.6) day workers. There were no differences in the studied variables between shift workers and day workers. Results of correlation analysis demonstrated that pulse wave velocity, central systolic blood pressure, central diastolic blood pressure, brachial systolic blood pressure, and brachial diastolic blood pressure tended to have significant correlation with each other, while these measures did not have a significant relationship with augmentation index in both groups. However, results of adjusted restricted cubic spline analysis showed a U-shaped-curve association between total sleep time and augmentation index (p < 0.001 for trend) with a nadir at 300-360 min of total sleep time in shift workers. The present study showed that total sleep time, assessed by actigraphy, had a U-shaped association with augmentation index in shift workers, which indicated better characteristics of vascular functionality when sleep time was 5-6 h in the workers studied.

Foot drop in critically ill patients: a narrative review of an elusive complication with intricate implications for recovery and rehabilitation.

Foot drop is a condition characterized by the inability to lift the foot upwards towards the shin bone. This condition may affect a proportion of critically ill patients, impacting on their recovery after the acute phase of the illness. The occurrence of foot drop in critical care patients may result from various underlying causes, including neurological injuries, muscular dysfunction, nerve compression, or vascular compromise. Understanding the etiology and assessing the severity of foot drop in these patients is essential for implementing appropriate management strategies and ensuring better patient outcomes. In this comprehensive review, we explore the complexities of foot drop in critically ill patients. We search for the potential risk factors that contribute to its development during critical illness, the impact it has on patients' functional abilities, and the various diagnostic techniques adopted to evaluate its severity. Additionally, we discuss current treatment approaches, rehabilitation strategies, and preventive measures to mitigate the adverse effects of foot drop in the critical care setting. Furthermore, we explore the roles of critical care physical therapists, neurologists, and other healthcare professionals in the comprehensive care of patients with foot drop syndrome and in such highlighting the importance of a multidisciplinary approach.

Inter- and Intra-donor variability in bone marrow–derived mesenchymal stromal cells: implications for clinical applications

Background aimsMesenchymal stromal cells (MSCs) are attractive as a therapeutic modality in multiple disease conditions characterized by inflammation and vascular compromise. Logistically they are advantageous because they can be isolated from adult tissue sources, such as bone marrow (BM). The phase 2a START clinical trial determined BM-MSCs to be safe in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Herein, we examine a subset of the clinical doses of MSCs generated for the phase 2a START trial from three unique donors (1–3), where one of the donors’ donated BM on two separate occasions (donor 3 and 3W). MethodsThe main objective of this study was to correlate properties of the cells from the four lots with plasma biomarkers from treated patients and relevant to ARDS outcomes. To do this we evaluated MSC donor lots for (i) post-thaw viability, (ii) growth kinetics, (iii) metabolism, (iv) surface marker expression, (v) protein expression, (vi) immunomodulatory ability and (vii) their functional effects on regulating endothelial cell permeability. ResultsMSC-specific marker expression and protection of thrombin-challenged endothelial barrier permeability was similar among all four donor lots. Inter and intra-donor variability was observed in all the other in vitro assays. Furthermore, patient plasma ANG-2 and protein C levels at 6 hours post-transfusion were correlated to cell viability in an inter- and intra-donor dependent manner. ConclusionsThese findings highlight the potential of donor dependent (inter-) and collection dependent (intra-) effects in patient biomarker expression.

Ischaemic Gastropathy: An Under-Recognised cause of Abdominal Pain.

Awareness needs to be increased regarding the consideration of ischaemic gastropathy as a differential diagnosis.A patient without a history of vascular compromise could have a diagnosis of ischaemic gastropathy.This is possibly the first noted case of ischaemic gastropathy occurring after an appendectomy, which is complicated by gram-negative bacteraemia and haemodynamic instability.

Should I stay or should I go: an assessment of criteria for safe day of surgery discharge of displaced supracondylar humerus fractures.

Immobilization type and in-hospital observation following surgical management of displaced supracondylar fractures are subject to surgeon preference and training. Our goal was to determine criteria for immediate discharge and optimal type of immobilization. Medical records of 661 patients with type III, IV or flexion-type displaced supracondylar humerus fractures treated at a level 1 pediatric trauma center from January 2013 to September 2019 were reviewed. Patients were separated into 'admission appropriate' (AA = 113) and 'discharge appropriate' (DA = 548) sub-cohorts. Neurovascular deficit at presentation ( P < 0.001), post-operative physical exam deterioration ( P < 0.001), age ( P < 0.001) and post-operative immobilization modality ( P = 0.02) were significantly different between AA and DA groups. When comparing patients who presented with neurologic deficit to those neurovascularly intact, there was a significant difference in whether circumferential immobilization was used post-operatively ( P < 0.001), IV medication need ( P < 0.001), discharge or admission ( P < 0.001), neurologic decline ( P < 0.001), return to ED ( P = 0.008) and vascular compromise ( P = 0.05). Twenty-four of the 56 (43%) patients who were AA and had no neurovascular finding on presentation had their immobilization adjusted (bivalved or loosened) to accommodate for swelling overnight. Only 1 was initially maintained in a splint or bivalved cast; the other 23 were initially maintained post-operatively in circumferential immobilization ( P = 0.01). Our findings suggest that patients with intact neurovascular exams at presentation are candidates for early discharge, and splinting or bivalved casting may be preferable, especially in patients who are discharged.

Aortoesophageal fistula with formation of secondary aortic pseudoaneurysm due to esophageal neoplasia: case report

Aortoesophageal fistula as a cause of upper gastrointestinal bleeding is a very rare event with a high immediate mortality rate. Some of the causes include foreign bodies, post-surgical complications, and malignancy. The following case describes how esophageal cancer invaded the walls of the descending aorta, leading to the formation of a pseudoaneurysm that subsequently fistulized into the esophagus, secondary to radiotherapy treatment. This case highlights the importance of evaluating the thoracic aorta before and during radiotherapy treatments, to investigate the existence of aortic vascular compromise adjacent to the esophagus. If the existence of an aortic pseudoaneurysm is detected, radiotherapy treatment should be suspended until the pseudoaneurysm is corrected, reducing the lethality of patients undergoing advanced treatments.

A49 AN UNEXPECTED CASE OF SEVERE PROTEIN-LOSING ENTEROPATHY IN A TODDLER

Abstract Background Protein-losing enteropathies (PLE) are characterized by excess loss of serum proteins into the gastrointestinal tract, resulting in hypoproteinemia, peripheral edema, and related respiratory and cardiac sequelae. PLE should be suspected in patients with hypoproteinemia not explained by protein malnutrition, impaired hepatic protein synthesis, or renal losses, and can occur as a consequence of erosive or non-erosive gastrointestinal diseases, and conditions that alter lymphatic flow. Aims To present a case of intestinal malrotation with chronic volvulus presenting as PLE. Methods In this report, we describe a pediatric patient presenting with PLE ultimately found to have intestinal malrotation with chronic volvulus. Results A healthy 1-year-old male presented with acute non-bloody diarrhea and peripheral edema on a background of recurrent colicky abdominal pain and non-bilious emesis. He had significant electrolyte derangements at presentation including hypokalemia, hyponatremia, hypomagnesemia, and metabolic acidosis, with additional laboratory findings of hypoalbuminemia (11g/L), hypogammaglobulinemia (IgA 0.11g/L, IgG 0.77g/L, IgM 0.28g/L), lymphopenia (0.4x10E9/L), and fat-soluble vitamin deficiency (Vitamin A 0.5umol/L, 25-Hydroxyvitamin D 18.4nmol/L, Vitamin E 6umol/L, INR 1.7). In addition to abdominal imaging, he underwent endoscopic evaluation which did not identify an underlying etiology. As his presentation was consistent with PLE, a high-protein, low-fat diet was initiated. Despite dietary adherence for 16 weeks, the PLE features persisted with ongoing severe hypoalbuminemia (20g/L). Given a suspicion of intestinal lymphangiectasia, a capsule endoscopy was arranged. In the interim, the patient had recurrence of abdominal pain and emesis prompting a repeat abdominal ultrasound which demonstrated swirling of the mesenteric vessels in the midline. An upper gastrointestinal series identified a short mesenteric root with the duodenojejunal junction and cecum in proximity. Urgent laparotomy confirmed a 720-degree volvulus of the small bowel around the mesenteric root, with an abnormally positioned duodenojejunal flexure and cecum. This was presumed to be chronic given the absence of acute vascular compromise. The patient underwent a Ladd procedure. He had complete resolution of symptoms and PLE features on a liberalized diet. Conclusions This report identifies a case of intestinal malrotation with chronic volvulus presenting as PLE, highlighting an atypical presentation of intestinal malrotation outside the neonatal period. Awareness of these atypical presentations is important to facilitate prompt diagnosis and treatment, thereby reducing the rate of complications. Funding Agencies None

Overview and management of complications after digital replantations.

The main complications after digital replantation are discussed in this review article. These complications include vascular compromise, infection, partial necrosis, delayed union or nonunion, atrophy and so on. The countermeasures for these complications are reviewed and the authors' methods are also introduced and discussed.

Clinical utility of smartphone-based digital infrared thermal imaging in predicting vascular compromise in free flaps

Abstract Background: Flap monitoring plays an important role in avoiding morbidity in free flap. Clinical monitoring is considered the gold standard, but it is subjective. Digital thermal imaging captures and displays the infrared radiation emitted from an object. This is useful in assessing temperature difference between two surfaces, as well as variation of temperature. Smartphone thermal imaging can be used to assess the tissue perfusion, which requires little training. Materials and Methods: The aim was to assess the validity of Digital Thermal Imaging in early diagnosis of flap failure, compared to conventional clinical methods. Eleven patients of microvascular-free flap reconstruction for defects following malignancy and trauma were included in the study for January 25, 2019–March 25, 2021. Flaps were monitored using three different methods – clinical monitoring, biochemical monitoring, and digital thermal imaging done at the following interval: (1) intraoperative (end of surgery), (2) hourly – for the first 48 h, (3) every 4th hourly on postoperative days 3–5, and (4) every 6th hourly on postoperative days 5–10, and the results were tabulated. Results: Flap temperature was observed to be higher compared to the surrounding skin when there was an event of venous thrombosis. The surrounding skin temperature was to be measured on the side opposite to the side where the flap was raised to do vascular anastomosis. The increase in the temperature difference almost coincided with the clinical and biochemical indicator of failing flaps. Conclusion: Monitoring of the flap temperature and comparing it with the surrounding skin temperature can be incorporated along with the gold standard. It is a simple, objective, and noncontact method compared to clinical monitoring and biochemical methods. A large sample size, multicentric, randomized controlled study is required to validate the same.

Omental Infarction, a Rare Case of Abdominal Pain: A Case Report and Literature Revue

Omental infarction is a rare cause of acute abdomen resulting from vascular compromise of the greater omentum. This condition has a non-specific clinical presentation that mimics other causes of acute abdomen, namely, acute appendicitis and cholecystitis. A confident diagnosis can usually be made on computed tomography (CT) and the typical natural history is one of spontaneous resolution. We present a case of a 59-year-old female patient, who has undergone surgery twice for a white line hernia, with the most recent operation having been performed one year ago. She presented to the emergency department with recent worsening of chronic abdominal pain. Omental infarction should be included in the differential diagnosis list of acute abdominal pain because it can occur at any site. In addition, because this disease runs a self-limited course, conservative care is recommended. Thus, unnecessary operations can be avoided in cases where omental infarction is diagnosed by imaging studies.

Shorter Ureters Lead to Fewer Strictures Following Cystectomy and Urinary Diversion

To identify the impact of length of distal ureteral resection on the risk of benign uretero-enteric anastomotic stricture (UEAS) formation following cystectomy and urinary diversion. A database of patients who underwent cystectomy and urinary diversion from 2015 to 2022 was analyzed. Distal ureteral resections were sent for final pathology. The length of resected ureter was collected from pathology reports. Benign UEAS were confirmed with renal scintigraphy, antegrade nephrostogram, or endoscopic evaluation. The relationship between stricture formation and clinical parameters were assessed using T-tests, Chi-square tests, and multivariable analysis. A total of 366 patients underwent cystectomy and urinary diversion. Of the cohort, 35 (9.5%) patients developed UEAS. Median time to stricture formation was 12.5 months (IQR 4-30). Of the 711 uretero-enteric anastomoses, 40 (5.6%) ultimately formed a UEAS. Median distal ureteral resection was significantly longer among ureteral anastomoses which did not form a UEAS (2.3 cm vs. 1.65 cm, p=0.028). Multivariable logistic regression adjusting for surgical approach, prior radiation, ureteral side, and urinary diversion type demonstrated that longer distal ureteral resections were inversely associated with odds of UEAS formation (OR 0.73, 95% CI 0.58-0.92). Multivariable Cox regression analysis similarly showed that length of distal ureteral resection was inversely associated with time to stricture formation (HR 0.78, 95% CI 0.62-0.98). The etiology of benign UIA strictures is multifactorial. Vascular compromise is a critical hypothesis. We found that longer distal ureteral resections (and thus shorter ureters) were associated with a significantly lower risk of stricture formation in cystectomy patients.

IGF-I protects porcine granulosa cells from hypoxia-induced apoptosis by promoting homologous recombination repair through the PI3K/AKT/E2F8/RAD51 pathway.

Severe hypoxia induced by vascular compromise (ovarian torsion, surgery), obliteration of vessels (aging, chemotherapy, particularly platinum drugs) can cause massive follicle atresia. On the other hand, hypoxia increases the occurrence of DNA double-strand breaks (DSBs) and triggers cellular damage repair mechanisms; however, if the damage is not promptly repaired, it can also induce the apoptosis program. Insulin-like growth factor-I (IGF-I) is a polypeptide hormone that plays essential roles in stimulating mammalian follicular development. Here, we report a novel role for IGF-I in protecting hypoxic GCs from apoptosis by promoting DNA repair through the homologous recombination (HR) process. Indeed, the hypoxic environment within follicles significantly inhibited the efficiency of HR-directed DNA repair. The presence of IGF-I-induced HR pathway to alleviate hypoxia-induced DNA damage and apoptosis primarily through upregulating the expression of the RAD51 recombinase. Importantly, we identified a new transcriptional regulator of RAD51, namely E2F8, which mediates the protective effects of IGF-I on hypoxic GCs by facilitating the transcriptional activation of RAD51. Furthermore, we demonstrated that the PI3K/AKT pathway is crucial for IGF-I-induced E2F8 expression, resulting in increased RAD51 expression and enhanced HR activity, which mitigates hypoxia-induced DNA damage and thereby protects against GCs apoptosis. Together, these findings define a novel mechanism of IGF-I-mediated GCs protection by activating the HR repair through the PI3K/AKT/E2F8/RAD51 pathway under hypoxia.

Observing vessel stumps axially: A novel exoscope for end-to-end microvascular anastomosis

Although many free tissue transfers have been performed, free flap loss can still occur because of vascular compromise. To facilitate microsurgery, we invented the axial-view microscope (aMS), a new type of microscope that can axially visualize vessel stumps. The aMS was combined with an optical microscope, the so-called bird’s-eye-view microscope (bMS). Using our aMS, we observed the cross-sections of the following 12 arteries during vascular anastomosis: three deep inferior epigastric arteries, three suprathyroid arteries, two thoracodorsal arteries, two jejunal arteries, one lateral circumflex femoral artery, and one facial artery. For each artery, we measured the vessel height-to-width (H–W) ratio to determine the roundness of the vessel stump. Based on the aMS and bMS, the average H–W ratios were 0.877 ± 0.187 and 0.445 ± 0.172, respectively. The H–W ratio obtained using the aMS was significantly higher than that of the bMS (P < 0.001). Providing the surgeon with a bidirectional view of the vessel stump reduced blind spots at the anastomotic site. In this report, we describe our new microscope and associated clinical cases.

Chronic subdural haematoma: a case series of uncommon presentations of a common disease

Abstract Chronic subdural haematoma is a common neurological condition especially among the elderly population. Its presentation can be unspecific but often attributed to pressure, cortical irritation, and/or vascular compromise. In the patients’ cohort presented below, we have a series of cases where clinical history and examination did not result in an initial clinical diagnosis or suspicion of chronic subdural haematoma, with the diagnosis made only after brain imaging. We reviewed the literature regarding the aetiopathogenesis and clinical features of our patient cohort, which included a young woman with isolated right ptosis and pupillary dilatation, an elderly man with paraplegia, another elderly man with isolated right foot drop, and a young military man with no history of trauma. Our series re-emphasizes the sometimes non-specific and varied clinical presentation of chronic subdural haematoma. We reiterate the need for early brain imaging in patients who present with neurological disorder.

Immune Checkpoint Inhibitors and the Risk of Cardiovascular Adverse Events: A Pooled Clinical Trial Database Analysis

Introduction Immune checkpoint inhibitors (ICIs) are a highly effective class of cancer immunotherapy, but their use has been limited by immune-related adverse events (irAEs) affecting various organ systems. Recent real-world studies have shown higher incidence rates of cardiovascular (CV) events in patients with cancer who are treated with ICIs compared to those treated with conventional chemotherapy (Laenens et al, J Clin Oncol 2022). Studies suggest that the underlying mechanism involves a pro-inflammatory response causing unintended vascular compromise, but there have been limited data on ICI-related cardiotoxicity across pooled datasets. Given that ICIs have been applied to lung cancer treatment in recent years, we use it as an example indication to study clinical trial (CT) patients with advanced non-small cell lung cancer (aNSCLC) randomized to either a first-line (1L) ICI-containing regimen or to 1L chemotherapy alone (chemo) to evaluate for potential differential rates of CV events. Methods We pooled patient-level, phase 3 CT data on aNSCLC patients treated with ICI or chemo from the Medidata Enterprise Data Store. Treatment assignment was the main variable of interest. The primary outcome was a composite CV event (acute coronary syndrome, heart failure, stroke, transient ischemic attack), occurring between the start of study treatment (index date) and 30 days following the last dose of study treatment. Incidence rates and the relative hazard of a CV event by treatment assignment were estimated. Additionally, the risk of CV event with non-CV death treated as a competing risk was estimated using the Fine-Gray model. In a post-hoc subgroup analysis we explored the impact of treatment assignment on overall survival (OS) among patients with and without baseline vascular disease. OS was defined as the time from the index date until the date of death (all-cause). Patients alive at the end of CT follow-up were censored. Results A total of 1862 patients were included in this analysis, with 1128 (60.6%) randomized to ICI and 734 (39.4%) to chemo. Baseline demographics and comorbidities were balanced across treatment groups. Forty-six (2.5%) patients experienced at least 1 CV event. The incidence rate of CV events was 2.48 times (95% CI: 1.10, 6.57) higher among patients treated with ICI compared to chemo. The unadjusted hazard of composite CV event, estimated using Kaplan-Meier, differed significantly by treatment assignment (p= 0.008) ( Figure 1). After adjusting for baseline demographics and comorbidities, the hazard of a composite CV event remained higher for patients treated with ICI compared to chemo (aHR 2.68, 95% CI: 1.19-6.06) ( Table 1). Baseline vascular disease history (N=359; 19.3%) was also associated with an increased hazard of a CV event (aHR: 2.40; 95% CI: 1.25-4.60). Similar results were found in the competing risk analysis. In the subgroup analysis, patients without baseline vascular disease history had a significant OS benefit from an ICI compared to chemo (aHR 0.84, 95% CI: 0.75-0.95), whereas patients with baseline vascular disease did not (aHR 1.00, 95% CI: 0.78-1.27). Conclusion Though ICIs enhance the body's immune responses against cancer, it is important to study the associated effect of irAEs on off-target tissues. These analyses of historical CT data suggest a positive association between 1L treatment of aNSCLC with ICI and subsequent composite CV events compared with chemo alone. Given the high prevalence of morbidity among patients with lung cancer, the use of concomitant cardioprotective therapies may be an important consideration when treating cancer populations with ICIs. Pooling CT data increases the power to detect clinically important differences in rare toxicities and may inform future research and patient-physician decision-making regarding the suitability of ICI use in aNSCLC treatment. Furthermore, this research highlights the potential clinical utility of drug repurposing: expanding the use of drugs approved to treat CV events and exploring their use in patients with vascular disease who are also being treated with ICIs. As cell-mediated immune responses play a key role in the potential CV effects of ICI treatments, future studies are needed to define the underlying mechanisms of ICI-related dysregulation of the immune system to better monitor patients and improve clinical outcomes in the context of immunotherapy for aNSCLC and other cancer types.

Central retinal artery occlusion following pediatric blunt ocular trauma.

To analyze the clinical profile, presentation, possible pathophysiology, and outcomes of central retinal artery occlusion (CRAO) following blunt trauma in pediatric subjects. The medical charts of subjects aged 18 years or less with a diagnosis of CRAO following blunt ocular trauma were analyzed retrospectively for demography, details of the trauma, ocular findings, additional imaging reports if any, and final outcome. A Medline search was done (key words like central retinal artery occlusion, blunt trauma, children, pediatric subjects, and adolescents) to gather information available in the literature on the subject. A total of 11 patients (11 eyes), mean age of 14.3 ± 3.4 years, and 100% male preponderance, with an average time duration from trauma to presentation to the hospital of 8.1 days were included. Visual acuity ranged from no light perception (four eyes) to finger count at a 1 m distance. Intraocular pressure was raised in three patients, of which two were suffering from sickle cell disease. In two eyes, the CRAO coexisted with optic nerve avulsion and the cilioretinal artery was spared. Disk pallor was seen in six eyes as early as 12 days from the trauma. None of the cases revealed any bony fracture in the CT scan. CRAO was observed to be an important primary or contributory cause of visual loss in children following blunt trauma, reflex vasospasm being the most common etiology. Early onset disk pallor could suggest an underlying vascular compromise of both retinal and optic disk circulation in addition to direct disk damage.

Indications for computed tomography angiography in limb trauma.

Computed tomography angiograms (CTAs) are useful in detecting vascular injury. There is a lack of consensus regarding the indications of CTAs in limb trauma, leading to overutilisation of CTAs in some centres and exposing patients to unnecessary harm. Thus, the aim of this study is to define the appropriate indications for CTAs in limb trauma. This is a retrospective cohort study of consecutive CTAs performed in a tertiary hospital from January to December 2022. Demographic and clinical factors were collected from the patients' charts including physical examination findings and arterial pressure index (API) measurements. Physical examination findings include hard signs (e.g. absent pulse) or soft signs (e.g. non-expanding haematoma). These data were analysed to detect correlation with vascular injury on the patient's CTA. Forty-nine CTAs were included, of which 10 (20.4%) found vascular injury. Hard signs (P < 0.001) and an API <0.9 (P = 0.02) were significantly correlated with vascular injury. Hard signs had a sensitivity of 90% and specificity of 82%, whereas APIs had a specificity and sensitivity of 100%. Soft signs were not correlated with vascular injury due to poor specificity but had a sensitivity of 100%. Knee dislocations were not associated with vascular injury (P = 0.5). This small study suggests that CTAs are indicated if there are hard signs of vascular compromise or an API <0.9, provided the patient is haemodynamically stable. The presence of soft signs can help identify which patients should receive an API measurement. CTAs may not be routinely indicated in knee dislocations.