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Management of anticoagulant treatment in patients who need non-cardiac surgery
No full textThe periprocedural management of anticoagulation in patients who require non-cardiac surgery is a common clinical problem due to the aging of the population associated with both an increase in the use of anticoagulants and a higher need for surgery. If surgery is needed in a patient on anticoagulant therapy, regardless of the drug used, it is necessary to consider the urgency of the surgical procedure and the balance between the thromboembolic risk related to the discontinuation of therapy and the hemorrhagic risk related to the surgical procedure itself. Finally, a topic still much discussed that derives from the combined evaluation of these factors is the possible indication of a bridge therapy (“bridging anticoagulation”) to limit the thromboembolic risk related to the discontinuation of treatment. The different strategies in patients under antivitamin K and direct oral anticoagulants are reviewed
Early and mid-term results in patients undergoing primary CABG in comparison with patients with PCI prior to CABG
No full textAim: We evaluated the impact of prior percutaneous coronary intervention (PCI) on early and mid-term results in patients undergoing coronary artery bypass grafting (CABG).Methods: Between 2015 and 2020, 938 consecutive patients (mean age 67.4 ± 9.11 years) underwent CABG with prior PCI (n = 121) or primary CABG (n = 817). The mean follow-up was 37 ± 25 (median 36) months. Kaplan-Meier estimates were used to assess survival rates, while Logistic and Cox model analysis regressions assessed the risk of prior PCI and other variables.Results: Six-year survival including in-hospital mortality was 79% ± 6% in CABG with prior-PCI patients vs.88% ± 2% in primary CABG (P = 0.002). As compared with primary CABG, in prior-PCI patients, clinical presentation (acute coronary syndrome, reduced left ventricular ejection fraction, and previous myocardial infarction, P ≤ 0.01, for all comparisons) was worse, comorbidity increased (Euroscore-2, severe chronic renal dysfunction, P < 0.01), and in-hospital mortality was higher (6.6% or 8 patients vs. 1.6% or 13 patients, P < 0.001). Prior PCI was found to be an independent predictor of mortality (HR = 4.23; P = 0.01). Six-year freedom from late all-cause death and cardiac death were 84% ± 6% vs. 90% ± 2% (P = 0.2) and 96% ± 2% vs. 96% ± 1% (P = 0.5), respectively. Independent predictors of all-cause death were advanced age at the operation (P < 0.0001), reduced left ventricular ejection fraction (P = 0.01), severe chronic renal dysfunction (P = 0.02), prior PCI (P = 0.03), and Euroscore-2 (P = 0.05). Prior PCI did not negatively affect late cardiac death (P = 0.5).Conclusion: Patients undergoing CABG after prior PCI have worse perioperative outcomes. Mid-term reduced survival in the prior-PCI patients is mainly due to the concomitant presence of worse clinical presentation and increased comorbidity. Freedom from cardiac death is comparable and satisfactory in both cohorts, highlighting the positive protective effect of CABG over time
Loss of HER2 in breast cancer: biological mechanisms and technical pitfalls
No full textLoss of HER2 in previously HER2-positive breast tumors is not rare, occurring in up to 50% of breast cancers; however, clinical research and practice underestimate this issue. Many studies have reported the loss of HER2 after neoadjuvant therapy and at metastatic relapse and identified clinicopathological variables more frequently associated with this event. Nevertheless, the biological mechanisms underlying HER2 loss are still poorly understood. HER2 downregulation, intratumoral heterogeneity, clonal selection, and true subtype switch have been suggested as potential causes of HER2 loss, but translational studies specifically investigating the biology behind HER2 loss are virtually absent. On the other side, technical pitfalls may justify HER2 loss in some of these samples. The best treatment strategy for patients with HER2 loss is currently unknown. Considering the prevalence of this phenomenon and its apparent correlation with worse outcomes, we believe that correlative studies specifically addressing HER2 loss are warranted
β-cyclodextrin mediated construction of porous helical nanoribbons from oligoaniline derivatives
No full textA novel supramolecular self-assembly nanostructure of porous helical nanoribbons (PHNRs) was developed. PHNRs from oligoaniline derivatives were fabricated through the chemical oxidation of aniline in an i-propanol/water mixture as mediated by β-cyclodextrin (β-CD). The role of β-CD was considered vital through the modulation of the addition time point of β-CD and the molar ratio of β-CD/aniline. In addition, at the early stage of polymerization, the host-guest complex between oligoaniline and β-CD was formed, which was involved in the initial supramolecular assembly process. However, with the reorganization of the oligoaniline assemblies during the polymerization time, the abscission of β-CD from the helical nanoribbons was observed, which eventually induced the formation of PHNRs. We believe the supramolecular host-modulated assembly strategy presented herein will be instructive for the fabrication of porous supramolecular nanostructures
Advances in upper limb loss rehabilitation: the role of targeted muscle reinnervation and regenerative peripheral nerve interfaces
No full textUpper limb loss results in significant physical and psychological impairment and is a major financial burden for both patients and healthcare services. Current myoelectric prostheses rely on electromyographic (EMG) signals captured using surface electrodes placed directly over antagonistic muscles in the residual stump to drive a single degree of freedom in the prosthetic limb (e.g., hand open and close). In the absence of the appropriate muscle groups, patients rely on activation of biceps/triceps muscles alone (together with a mode switch) to control all degrees of freedom of the prosthesis. This is a non-physiological method of control since it is non-intuitive and contributes poorly to daily function. This leads to the high rate of prosthetic abandonment. Targeted muscle reinnervation (TMR) reroutes the ends of nerves in the amputation stump to nerves innervating “spare” muscles in the amputation stump or chest wall. These then become proxies for the missing muscles in the amputated limb. TMR has revolutionised prosthetic control, especially for high-level amputees (e.g., after shoulder disarticulation), resulting in more intuitive, fluid control of the prosthesis. TMR can also reduce the intensity of symptoms such as neuroma and phantom limb pain. Regenerative peripheral nerve interface (RPNI) is another technique for increasing the number of control signals without the limitations of finding suitable target muscles imposed by TMR. This involves wrapping a block of muscle around the free nerve ending, providing the regenerating axons with a target organ for reinnervation. These RPNIs act as signal amplifiers of the previously severed nerves and their EMG signals can be used to control prosthetic limbs. RPNI can also reduce neuroma and phantom limb pain. In this review article, we discuss the surgical technique of TMR and RPNI and present outcomes from our experience with TMR
Artificial intelligence and its role in guiding liver-directed therapy for hepatocellular carcinoma: Is it ready for prime time?
No full textArtificial intelligence (AI) is an innovative discipline in medicine, impacting both hepatology and hepato-pancreato-biliary surgery, ensuring reliable outcomes because of its repeatable and efficient algorithms. A considerable number of studies about the efficiency of AI in the management of hepatocellular carcinoma (HCC) have been published. While its diagnostic role is well recognized, providing large amounts of quantitative radiological HCC features, its use in HCC treatment is still debated. Innovative use of AI may help to select the best approach for each patient as it is able to predict the outcomes after resection and/or other treatments. In this review, we assess the role of AI in selecting the best therapeutic option and predicting long-term risks after surgical or interventional treatments for HCC patients. Further studies are needed to consolidate AI applications
Why Artificial Intelligence Surgery (AIS) is better than current Robotic-Assisted Surgery (RAS)
No full text
Routine plain film of abdomen in asymptomatic patients with video capsule retention in small bowel-time to change practice?
No full textAim: Small bowel capsule retention is rare, with a rate of approximately 2%, defined as visible retention on plain film of abdomen (PFA) after 14 days. Currently, PFA is performed if the capsule is not seen to reach the large bowel during recording. Alternatively, for upper gastrointestinal (UGI) capsule studies, the risk of retention is determined if the capsule fails to reach the small bowel during recording. Given the similar physical specifications of the capsules (Medtronic) used, we considered whether 14-day PFA is no longer required for small bowel capsules not observed in the large bowel.Methods: The use of patency capsules in our lab allows careful selection of small bowel capsule studies to minimize the risk of retention. All PFAs performed over a five-year period were reviewed to determine if careful selection and use of patency negate the need for capsule retention PFA screening.Results: In total, 688 small-bowel capsules were performed during the study period, and 3.6% had prior patency capsules. Thirty-one PFAs with a query of capsule retention were performed during the study period on 28 patients. This included 15 females, and the median age was 53.5 years. None of the films demonstrated capsule retention.Conclusion: Our data suggest that 14-day PFA may no longer be required for small bowel capsules not seen to reach the large bowel. Advice regarding symptoms of capsule retention and precaution with magnetic resonance imaging, similar to current UGI capsule advice, may suffice. This may reduce the burden on radiology imaging slots and, in particular, eliminate unnecessary radiation exposure and repeat hospital attendance for patients
Reflux and bariatric surgery: a review of pre-operative assessment and post-operative approach
No full textBariatric surgery is the cornerstone of treatment for severe obesity. In evaluating patients for such procedures, surgeons must be aware of the potential complications, including post-operative gastroesophageal reflux disorder (GERD). This review article outlines the current literature regarding GERD prior to and after bariatric surgery. It aims to establish a framework for evaluating and managing GERD in both the pre- and post-operative setting for common bariatric procedures such as the sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric band, duodenal switch type procedures as well as one-anastomosis gastric bypass. This review also outlines the latest recommendations from major international bariatric societies for screening prior to surgery, the incidence of GERD after each respective procedure and a summary of current trends in the management of post-operative GERD after bariatric surgery
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