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Nationwide Incidence and Trends in Central Retinal Arterial Occlusion Management: A 5000-Patient Analysis
No full textCentral retinal artery occlusion (CRAO) is a rare and visually debilitating vascular condition characterized by sudden and severe vision loss. CRAO is a compelling target for intravenous alteplase (tPA) and endovascular mechanical thrombectomy (MT) due to pathophysiological similarities with acute ischemic stroke; however, the utility of these interventions in CRAO remains dubious due to limited sample sizes and potential risks. To assess usage and outcomes of tPA and MT in CRAO, we queried the National Inpatient Sample database using International Classification of Disease, Ninth and Tenth edition for patients with CRAO and acute ischemic stroke between 2010 and 2019. Our cohort of 5009 CRAO patients were younger with higher rates of obesity, hypertension, long-term anticoagulant use, and tobacco use compared to acute ischemic stroke patients. CRAO patients had lower rates of tPA administration (3.41% vs 6.21%) and endovascular MT (0.38% vs 1.31%) but fewer complications, including deep vein thrombosis, pneumonia, urinary tract infection, acute kidney injury, and acute myocardial infarction (all P \u3c 0.01). CRAO patients had lower rates of poor functional outcome (31.74% vs 58.1%) and in-hospital mortality (1.2% vs 5.64%), but higher rates of profound blindness (9.24% vs 0.58%). A multivariate regression showed no relationship between tPA and MT and profound blindness, although the limited sample size of patients receiving interventions may have contributed to this apparent insignificance. Further investigation of larger patient cohorts and alternative treatment modalities could provide valuable insights for revascularization therapies in CRAO to optimize visual restoration and clinical outcomes
Robotic Assisted versus Manual Percutaneous Coronary Intervention: Systematic Review and Meta-Analysis
No full textIntroduction: Robotics in percutaneous coronary intervention (R-PCI) has been one such area of advancement where potential benefits may include reduced operator radiation exposure, improved outcomes, and reduced rate of adverse events. Limited data exist about the benefits of R-PCI versus conventional manual PCI (M-PCI). We appraised the latest evidence in the form of a meta-analysis of observational and retrospective studies. Methods: A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant clinical studies. Summary effects were calculated using a DerSimonian and Laird random-effects model as the pooled odds ratio or mean differences (MDs) with 95% confidence intervals (CIs). All studies adhering to the inclusion criteria of direct comparisons between R-PCI and M-PCI were evaluated. Results: Seven studies with a total of 2230 patients were identified. There was significant decrease in the chest-level operator radiation exposure (MD = -442.32; 95% CI = -675.88 to -208.76), fluoroscopy time (MD = -1.46; 95% CI = -2.92 to 0.00), and amount of contrast used (MD = -18.28; 95% CI = -24.16 to -12.41) in the robotic group compared to the manual group. PCI time and the procedural success rate was not statistically different between the 2 groups. Clinical outcomes of major adverse cardiac events, all-cause mortality, and myocardial infarction were not different between the 2 groups. Conclusions: Robotic PCI is associated with reduced operator radiation exposure, fluoroscopy time, and amount of contrast used. While there is a significant reduction in the procedural characteristics with robotic PCI, the clinical outcomes are not different compared to M-PCI. R-PCI is safe and effective with potential benefits to both the operator and the patient simultaneously
Impact of Tearcare on Reading Speed in Patients With Dry Eye Disease
No full textPurpose: To evaluate the impact of TearCare (TC) treatment on clinical, quality of life, and functional visual outcome metrics in patients with dry eye disease (DED) and meibomian gland disease (MGD). Methods: This is a prospective, single-center clinical trial. Adults with MGD and a DED diagnosis and tear break-up time (TBUT) \u3c10 seconds were included. All subjects had at least 20/40 vision and no surgery or new treatment for DED within 60 days prior to enrollment. All patients had one baseline visit prior to undergoing TC and one follow-up visit 1 month after TC. At each visit, the meibomian gland secretion score (MGSS), TBUT, and corneal fluorescein staining (KFL) were assessed. DED symptoms were evaluated using the Ocular Surface Disease Index (OSDI) questionnaire, Visual Function Questionnaire 25 (VFQ-25), and the Fatigue Severity Scale. Reading speed was determined through the International Reading Speed Texts (IReST), Minnesota Low Vision Reading Test (MNREAD), and Wilkins Rate of Reading Test (WRRT). Results: Thirty-two subjects were included. The average age was 55.9 years. Sixteen (52%) participants had a clinically significant improvement in reading speed after treatment with TC, defined as \u3e10 words per minute increase in their IReST score. Improvement on the IReST and the MNREAD reached statistical significance (p = 0.012 and p = 0.028, respectively). OSDI scores significantly decreased and VFQ-25 scores significantly increased after TC treatment (p \u3c 0.001). All of the clinical exam parameters showed statistically significant improvements after treatment (p \u3c 0.001). Conclusion: TC is an effective treatment both clinically and with respect to visual function. Patients who had TC exhibited improvements in quality of life and improved reading speed after a single treatment. This treatment should be frequently considered and utilized to reduce the disease burden of DED related to MGD
Escalation From Impella 5.5 to ECPELLA Support as a Bridge to Mitral Valve Surgery in a Patient With Degenerative Mitral Regurgitation
No full textSevere mitral regurgitation (MR) is an important cause of acute heart failure and significant contributor to morbidity and mortality. Mechanical circulatory support (MCS) devices such as Impella are readily used to hemodynamically stabilize patients with cardiogenic shock (CS) secondary to this valvular pathology. Impella can also be combined with VA-ECMO to an “ECPELLA” configuration if further escalation of hemodynamic support is needed. We report a case of a 57-year-old female who presented with CS secondary to a perforated anterior mitral valve leaflet and non-ischemic cardiomyopathy that did not stabilize with initial choice of Impella 5.5. She required further escalation from axillary Impella 5.5 to the combined ECPELLA configuration, which allowed hemodynamic stabilization and ultimately a successful high-risk isolated mitral valve replacement. Despite adequate Impella flow, escalation to a combined MCS configuration, such as ECPELLA, may need to be considered upfront for acute valvular insufficiency in the setting of pre-existing cardiomyopathy
Inadvertent Laparoscopic Lavage of Perforated Colon Cancer: A Systematic Review
No full textBackground: Although laparoscopic lavage for perforated diverticulitis with peritonitis has been grabbing the headlines, it is known that the clinical presentation of peritonitis can also be caused by an underlying perforated carcinoma. The aim of this study was to determine the incidence of patients undergoing inadvertent laparoscopic lavage of perforated colon cancer as well as the delay in cancer diagnosis. Methods: The PubMed database was systematically searched to include all studies meeting inclusion criteria. Studies were screened through titles and abstracts with potentially eligible studies undergoing full-text screening. The primary endpoints of this meta-analysis were the rates of perforated colon cancer patients having undergone inadvertent laparoscopic lavage as well as the delay in cancer diagnosis. This was expressed in pooled rate % and 95% confidence intervals. Results: Eleven studies (three randomized, two prospective, six retrospective) totaling 642 patients met inclusion criteria. Eight studies reported how patients were screened for cancer and the number of patients who completed follow-up. The pooled cancer rate was 3.4% (0.9%, 5.8%) with low heterogeneity (Isquare2 = 34.02%) in eight studies. Cancer rates were 8.2% (0%, 3%) (Isquare2 = 58.2%) and 1.7% (0%, 4.5%) (Isquare2 = 0%) in prospective and retrospective studies, respectively. Randomized trials reported a cancer rate of 7.2% (3.1%, 11.2%) with low among-study heterogeneity (Isquare2 = 0%) and a median delay to diagnosis of 2 (1.5–5) months. Conclusions: This systematic review found that 7% of patients undergoing laparoscopic lavage for peritonitis had perforated colon cancer with a delay to diagnosis of up to 5 months
Right Axillary Thoracotomy Should Be the Standard of Care for Repair of Non-Complex Congenital Heart Defects in Infants and Children
No full textMinimally invasive approaches for cardiac surgery in children have been lagging in comparison to the adult world. A wide range of the most common congenital heart defects in infants and children can be repaired successfully through a variety of non-sternotomy incisions. This has been shown to be associated with superior cosmetic results, shorter hospital stays, and rapid return to full activity compared to sternotomy. These approaches have been around for decades, but they have not been widely adopted for a variety of reasons. Right axillary thoracotomy is one of these approaches that we believe should be the new standard for the repair of a wide variety of heart defects in children and will be the focus of our current review
Development and Publication of Clinical Practice Parameters, Reviews, and Meta-Analyses: A Report From the Society of Cardiovascular Anesthesiologists Presidential Task Force
No full textThe Society of Cardiovascular Anesthesiologists (SCA) is committed to improving the quality, safety, and value that cardiothoracic anesthesiologists bring to patient care. To fulfill this mission, the SCA supports the creation of peer-reviewed manuscripts that establish standards, produce guidelines, critically analyze the literature, interpret preexisting guidelines, and allow experts to engage in consensus opinion. The aim of this report, commissioned by the SCA President, is to summarize the distinctions among these publications and describe a novel SCA-supported framework that provides guidance to SCA members for the creation of these publications. The ultimate goal is that through a standardized and transparent process, the SCA will facilitate up-to-date education and implementation of best practices by cardiovascular and thoracic anesthesiologists to improve patient safety, quality of care, and outcomes
Sharp Recanalization of CBD Occlusion in Patient With Second Orthotropic Liver Transplant With Cocoon Syndrome
No full textBiliary complications after orthotopic liver transplant (OLT) remain one of the primary causes of morbidity and mortality in liver transplant recipients with an approximate incidence between 5% and 32%. Given the limited supply of hepatic grafts, one of the most feared outcomes as a result of biliary complications is acute and or chronic graft failure. Biliary complications include leaks, biliary stasis, and stone formation, sphincter of Oddi dysfunction, recurrence of biliary disease (primary sclerosing cholangitis and primary biliary cirrhosis), and biliary strictures/obstruction. Overwhelmingly, the most common complication in hepatic transplantation is biliary stricture formation accounting for more than 50%. Currently, the mainstay of therapy as it pertains to biliary strictures/obstruction includes endoscopic retrograde cholangiography–guided therapy, percutaneous transhepatic cholangiography–guided therapy, or surgical revision/retransplantation. We present a case of biliary obstruction in a patient with a second liver transplant complicated by Cocoon Syndrome managed via sharp recanalization of CBD occlusion and placement of an endoscopic biliary Viabil stent
Feasibility and Analgesic Efficacy of Thoracolumbar Dorsal Ramus Nerve Block Using Multiorifice Pain Catheters for Scoliosis Surgery: A Prospective Cohort Study
No full textBackground: Approximately 38,000 scoliosis surgery correction operations are performed annually in the United States; these operations are associated with considerable postoperative pain which can be difficult to manage. This is largely attributed to an incision spanning multiple vertebral segments with paraspinal muscle dissection and retraction to facilitate the implantation of segmental hardware and rods. Frequently utilized analgesic modalities include intravenous patient-controlled analgesia and epidural analgesia, often in combination. We sought to ascertain the feasibility and analgesic efficacy of continuous thoracolumbar dorsal ramus nerve (TDRN) block using surgically placed multiorifice catheters. Methods: Forty-two patients diagnosed with idiopathic scoliosis who underwent a posterior spinal fusion (PSF) were enrolled after consent was obtained. Patients were managed utilizing a standardized Enhanced Recovery After Surgery) protocol including a perioperative opioid-sparing regimen. Data were collected at specified time intervals during the recovery period. These data points included pain scores using the Numeric Rating Scale. Parenteral or both oral and parenteral opioid consumption doses were also collected every 4 hours. Any significant postoperative adverse events were recorded as well. Results: A total of 42 patients had surgically placed TDRN catheters, and 40 patients were included in this study. The patients all reported low to moderate pain scores with low opioid consumption postoperatively, while the TDRN catheter delivery of local anesthetic analgesics did not result in significant complications. Clinical Relevance: A regional technique utilizing TDRN catheters could be a valuable component of the postoperative pain management protocols for PSF surgery, and additional studies are warranted. Conclusion: This study evaluated the feasibility and analgesic efficacy of TDRN catheters for postoperative pain control following multilevel PSF for idiopathic scoliosis. Continuous local anesthetic delivery through TDRN catheters is a feasible and safe technique for postoperative pain control in these patients. Selective blockade of the dorsal rami might have benefits over epidural analgesia or other regional techniques
PROJECT PREVENT: A Randomized Controlled Trial of Preoperative Vaginal Metronidazole to Decrease Patient Issues and Infections After Hysterectomy
No full textObjectives To evaluate if vaginal metronidazole for 5 days before hysterectomy decreases postoperative infections and patient issues. Design This randomized trial compared vaginal metronidazole for 5 days before a scheduled hysterectomy to no intervention. Sample size calculation was based on a 20% difference in issues and infection (30% incidence and 10% in the intervention arm) with 80% power and an alpha error of 0.05 and indicated 62 subjects needed in each arm. Setting Outpatient gynecology clinics at a single academic institution. Participants 154 subjects were screened for eligibility between July 2020 and September 2022. 133 underwent hysterectomy including 68 subjects (51.1%) randomized to the metronidazole and 65 (48.9%) controls. Overall, the population was racially and ethnically diverse. There was no significant difference in characteristics between the two groups. Interventions Vaginal metronidazole for 5 days before hysterectomy. Main outcome measures Postoperative patient issues and documented postoperative infections at 4-8 weeks after surgery. Results There was no difference in the composite rate of patient-reported issues and/or documented postoperative infection (53/133 (39.8%) with no difference between groups (29/68 (42.6%) vs 24/65 (36.9%), p=0.50). There was no difference in patient-reported issues which was 51/133 (38.3%) with no difference between groups (28/68 (41.2%) vs 23/65 (33.8%), p=0.49) or in documented infections with a rate of 25/133 (18.8%) with no significant difference between groups (15/68 (22.0%) vs 10/65 (15.4%), p=0.33). In the intervention arm, the compliance rate was 73.5% for all 5 days of vaginal metronidazole, and a per-protocol analysis was performed which resulted in no significant difference between groups. Conclusions There is insufficient evidence to suggest a significant benefit of preoperative vaginal metronidazole to prevent surgical site infections and postoperative patient issues in patients undergoing hysterectomy. Trial registration number ClinicalTrials.gov, NCT04478617