Heterogeneity of treatment response to beta-blockers in the treatment of portal hypertension: A systematic review.

BACKGROUND: It has been suggested that a relevant proportion of patients do not respond to nonselective beta-blockers (NSBB)s, which raises questions regarding the need for individualized therapy. The existence of potential heterogeneity in the treatment response can be assessed using the variability ratio (VR) of the outcome measurement (in this case, HVPG) between the treated and placebo groups. We conducted a systematic review and meta-analysis of randomized controlled trials to assess the potential heterogeneity in the portal pressure response to NSBBs. METHODS: After a systematic search, we quantified the heterogeneity of treatment response with the VR between the treatment and control groups, with VR > 1 indicating potential heterogeneity. We used a similar approach to compare carvedilol with propranolol and statins with placebo. RESULTS: We identified 18 studies that included 965 patients. A comparison between beta-blockers and placebo showed a pooled VR of 0.99 (95% CI:0.87-1.14), which suggests a homogeneous HVPG response to NSBB at the individual patient level (ie, no evidence to support that some patients responded to beta-blockers and others did not). For the comparison between carvedilol and propranolol, pooled VR was 0.97 (95% CI 0.82-1.14), suggesting that carvedilol achieves a greater average response (rather than an increase in the proportion of responders). There was no evidence of a heterogeneous response to statins. CONCLUSION: Our analysis did not support the existence of a heterogeneous patient-by-patient response to NSBBs in cirrhosis. These findings challenge the concept of personalized therapy based on portal pressure response and indicate that routine portal pressure measurement may not be necessary to guide NSBB therapy.

Retrospective record review on timing of COVID-19 vaccination and cardiac surgery.

BACKGROUND: Novel clinical challenges are faced by cardiac surgeons under the coronavirus disease 2019 (COVID-19) pandemic. Amidst the uncertainties faced due to the socioeconomic and public health impact, there is little evidence surrounding COVID-19 vaccination in patients undergoing cardiac surgery. Timing of vaccination and postvaccination adverse effects are required parameters to discuss with cardiac surgical patients. METHODS: This is a single-center, retrospective observational study. All patients who underwent adult cardiac surgery at the Prince of Wales Hospital, Hong Kong from January 2021 to December 2021 were included. Postoperative clinical outcomes, COVID-19 vaccination status, and vaccination-related adverse effects were collected. RESULTS: A total of 426 patients; 117 (27%) underwent isolated coronary artery bypass grafting, 111 (26%) underwent valvular surgery, and 97 (23%) underwent aortic surgery. Patients received either Sinovac CoronaVac or Pfizer BNT162b2 vaccine. Overall vaccination rate with at least 1 dose was 52% (n = 212), 15% (n = 63) received the first dose before surgery, 36% (n = 149) received the first dose vaccination after surgery. Rate of completion with second and third doses of vaccination were 22% (n = 89) and 4.9% (n = 20), respectively. The mean timing of first dose of vaccine after surgery was 216 ± 84 days from operation. Three (1.4%) patients recorded vaccination-related complications. CONCLUSIONS: COVID-19 vaccination is safe in patients who received major cardiac surgery, with low adverse effects recorded and no vaccine-related mortality observed. A time frame of 3-6 months after cardiac surgery receiving COVID-19 vaccination is reasonable and could serve as a guidance for future COVID-19 vaccination booster programs.

A Morphometric Analysis of Commonly Used Craniometric Approaches for Freehand Ventriculoperitoneal Shunting.

BACKGROUND: Ventricular catheter tip position is a predictor for ventriculoperitoneal shunt survival. Cannulation is often performed freehand, but there is limited consensus on the best craniometric approach. OBJECTIVE: To determine the accuracy of localizing craniometric entry sites and to identify which is associated with optimal catheter placement. METHODS: This is a retrospective analysis of adult patients who underwent ventriculoperitoneal shunting. The approaches were categorized as Kocher's, Keen's, Frazier's and Dandy's points as well as the parieto-occipital point. An accurately sited burr hole was within 10 mm from standard descriptions. Optimal catheter tip position was defined as within the ipsilateral frontal horn. RESULTS: A total of 110 patients were reviewed, and 58% (65/110) of burr holes were accurately sited. Keen's point was the most correctly identified (65%, 11/17), followed by Kocher's point (65%, 37/57) and Frazier's point (60%, 3/5). Predictors for accurate localization were Keen's point (odds ratio 0.3; 95% CI: 01-0.9) and right-sided access (odds ratio 0.4; 95% CI: 0.1-0.9). Sixty-three percent (69/110) of catheters were optimally placed with Keen's point (adjusted odds ratio 0.04; 95% CI: 0.01-0.67), being the only independent factor. Thirteen patients (12%) required shunt revision at a mean duration of 10 ± 25 mo. Suboptimal catheter tip position was the only independent determinant for revision (adjusted odds ratio 0.11; 95% CI: 0.01-0.98). CONCLUSION: This is the first study to compare the accuracy of freehand ventricular cannulation of standard craniometric entry sites for adult patients. Keen's point was the most accurately sited and was a predictor for optimal catheter position. Catheter tip location, not the entry site, predicted shunt survival.

Promoter methylation of ADAMTS1 and BNC1 as potential biomarkers for early detection of pancreatic cancer in blood.

BACKGROUND: Despite improvements in cancer management, most pancreatic cancers are still diagnosed at an advanced stage. We have recently identified promoter DNA methylation of the genes ADAMTS1 and BNC1 as potential blood biomarkers of pancreas cancer. In this study, we validate this biomarker panel in peripheral cell-free tumor DNA of patients with pancreatic cancer. RESULTS: Sensitivity and specificity for each gene are as follows: ADAMTS1 87.2% and 95.8% (AUC = 0.91; 95% CI 0.71-0.86) and BNC1 64.1% and 93.7% (AUC = 0.79; 95% CI 0.63-0.78). When using methylation of either gene as a combination panel, sensitivity increases to 97.3% and specificity to 91.6% (AUC = 0.95; 95% CI 0.77-0.90). Adding pre-operative CA 19-9 values to the combined two-gene methylation panel did not improve sensitivity. Methylation of ADAMTS1 was found to be positive in 87.5% (7/8) of stage I, 77.8% (7/9) of stage IIA, and 90% (18/20) of stage IIB disease. Similarly, BNC1 was positive in 62.5% (5/8) of stage I patients, 55.6% (5/9) of stage IIA, and 65% (13/20) of patients with stage IIB disease. The two-gene panel (ADAMTS1 and/or BNC1) was positive in 100% (8/8) of stage I, 88.9% (8/9) of stage IIA, and 100% (20/20) of stage IIB disease. The sensitivity and specificity of the two-gene panel for localized pancreatic cancer (stages I and II), where the cancer is eligible for surgical resection with curative potential, was 94.8% and 91.6% respectively. Additionally, the two-gene panel exhibited an AUC of 0.95 (95% CI 0.90-0.98) compared to 57.1% for CA 19-9 alone. CONCLUSION: The methylation status of ADAMTS1 and BNC1 in cfDNA shows promise for detecting pancreatic cancer during the early stages when curative resection of the tumor is still possible. This minimally invasive blood-based biomarker panel could be used as a promising tool for diagnosis and screening in a select subset of high-risk populations.

Bifid ureter with blind-ending branch: A rare anatomic variant detected during antegrade ureteric stent insertion.

Anatomic variants of the urinary tract are relatively common; however, a bifid ureter with a blind-ending branch is a rare congenital anomaly. This variant often goes unnoticed because patients are either asymptomatic or complain of vague abdominal symptoms. Diagnosis is often incidental, and may be missed on conventional imaging. Although bifid ureters usually do not require any specific investigations or treatment; it is important to have an appreciation for these anomalies particularly if radiological intervention or surgical procedures are planned. We describe a case of a blind-ending bifid ureter in a patient with bilateral hydronephrosis secondary to a large cervical malignancy. The presence of the bifid ureter was only appreciated during a technically challenging antegrade ureteric stent insertion several weeks after diagnosis. We review the clinical significance, embryology, and radiology findings of this anomaly, as well as the implications during radiological interventional procedures.

Association of antenatal steroid and risk of retinopathy of prematurity: a systematic review and meta-analysis.

BACKGROUND: Retinopathy of prematurity (ROP) is one of the leading causes of childhood blindness. Use of antenatal steroid can reduce neonatal morbidity and mortality in preterm births, but its effect on ROP remained controversial. We aim to determine the association between antenatal steroid and risk of ROP by a systematic review and meta-analysis. METHODS: Reported studies on the association between antenatal steroid and risk of ROP or severe ROP were identified from MEDLINE and Embase databases from their inception to November 2016. Outcome measures were ORs with 95% CIs. Extracted data were pooled using a random-effect model or fixed-effect model where appropriate. Heterogeneity was assessed, and sensitivity analysis was performed. RESULTS: A total of 434 relevant studies were identified, and 28 studies were eligible for the meta-analysis, involving 20 731 neonates with 4202 cases of ROP. Among the 28 studies included, 13 studies provided data evaluating the association between antenatal steroid use and severe ROP, involving 4999 neonates with 792 cases of severe ROP. Antenatal steroid administration was associated with a reduced risk of ROP development (ORunadjusted=0.82, 95% CI 0.68 to 0.98; ORadjusted=0.67, 95% CI 0.47 to 0.94) and progression to severe ROP (ORunadjusted=0.58, 95% CI 0.40 to 0.86). CONCLUSION: Antenatal steroid administration is associated with a reduced risk of ROP development and progression to severe ROP. Our results strengthened the indications of antenatal steroid therapy to high-risk mothers giving preterm births, especially in low-income and middle-income countries where antenatal steroid are not yet widely used.

A Pilot Study Assessing the Impact of 3-D Printed Models of Aortic Aneurysms on Management Decisions in EVAR Planning.

INTRODUCTION: Endovascular repair of aortic aneurysms with difficult anatomy is challenging. There is no consensus for planning such procedures. METHODS: Six cases of aortic aneurysms with challenging anatomical features, such as short, angulated, and conical necks and tortuous iliacs were harvested. The computed tomography (CT) scans were anonymized. Lifesize 3-dimensional (3-D) printed models were created of the lumen. Endovascular operators were asked to review the CT angiography (CTA), make a management plan, and give an indication of their confidence. They were then presented with the equivalent model and asked to review their decision. Their attitudes to such models were briefly surveyed. RESULTS: A total of 28 endovascular operators reviewed 144 cases. After review of the physical model, the management plan changed in 29 (20.1%) of 144 cases. Initial plan after CTA review was endovascular 73.6%, open repair 22.9%, and second opinion 3.5%. After model review, this became endovascular 67.4%, open repair 19.4%, and second opinion 4.8%. Although the general trend was toward more open procedures, off-label techniques reduced from 19.4% to 15.2% following model review. When the management plan did not change, level of confidence did increase in 37 (43.5%) of 85 cases. The majority of operators stated that they would find models useful for planning in some procedures. For 1 case, the change in the percentage of participants being sure in the management plan was statistically significant (P = .031). CONCLUSION: The 3-D printed models may be potentially useful in planning cases with EVAR. It is a paradigm that warrants further investigation.

Management of refractory haematuria following radiation therapy and recurrent adenocarcinoma of the prostate with fluoroscopic-guided selective pelvic embolization.

Haematuria is a known complication of prostatic malignancy and in severe cases can be unresponsive to bladder irrigation and endoscopic interventions. This report describes selective angiographic embolization as a means of haemorrhage control in adenocarcinoma of the prostate. A patient with locally advanced prostatic adenocarcinoma and prior history of prostate brachytherapy, androgen deprivation therapy and chemotherapy presented with persistent haematuria that did not respond to endourological intervention. He was successfully treated with selective embolization of the vesical and prostatic vessels under fluoroscopic guidance. Angiographic embolization represents a safe and effective means of achieving haemostasis in patients not fit for surgerywho would otherwise be resigned to terminal care treatment.

Transjugular intrahepatic portosystemic shunt in liver transplant recipients: indications, feasibility, and outcomes.

The role of transjugular intrahepatic portosystemic shunt (TIPS) for treating complications of portal hypertension after orthotopic liver transplantation (OLT) is unclear. In this review of 13 retrospective studies and 8 case reports comprising 213 patients, we assessed the indications, technical success, and clinical outcomes of TIPS procedures performed in patients who had undergone OLT. Indications for TIPS were refractory ascites (n = 168), variceal hemorrhage (n = 36), and hydrothorax (n = 9). Technical success was reported in 98% of cases. Five procedures failed because of portal vein thrombosis, caval tear, technical inability, patient instability, and unknown reasons (one each). Clinical success of TIPS after OLT was 57% in patients with refractory ascites, 69% in those with variceal hemorrhage, and 56% in those with hydrothorax. TIPS revision was required in 16% of cases, while 19% of patients underwent subsequent retransplantation. Postprocedural or worsening encephalopathy occurred in 33% of patients. Survival analysis based on 122 cases with data available revealed a 30-day mortality rate of 11%, a 1-year cumulative survival rate of 53%, and a 1-year cumulative retransplantation-free survival rate of 41%. Given the complexity of post-OLT cases with complications of recurrent portal hypertension, it is not surprising that the overall clinical success rate of TIPS was relatively low. Nevertheless, TIPS may remain a viable choice for the treatment of patients who have undergone OLT with recurrent portal hypertensive complications when medical therapy is unsuccessful.

Ethacrynic Acid continuous infusions in critically ill pediatric patients.

OBJECTIVES: The purpose of this study was to describe dosage regimens and treatment outcomes in critically ill children receiving ethacrynic acid continuous infusions (CI). METHODS: This retrospective cross-sectional study evaluated patients less than 18 years of age who received ethacrynic acid CI with a duration exceeding 12 hours, from January 1, 2007, through January 31, 2012. The primary objective was to determine the mean/median doses of ethacrynic acid CI. Secondary objectives were to assess surrogate efficacy markers (e.g., urine output [UOP], fluid balance) and the number of patients with electrolyte abnormalities or metabolic alkalosis. Descriptive statistics were used. A series of repeated measures analyses of variance were conducted to assess differences in surrogate efficacy markers and in adverse events that occurred pre-, mid-, and posttherapy. RESULTS: Nine patients were included. The mean ± SD initial and maximum doses (mg/kg/hr) were 0.13 ± 0.07 (median 0.1; range, 0.08-0.3) and 0.17 ± 0.08 (median, 0.16; range 0.09-0.3), respectively. The median UOP (mL/kg/hr) pre-, mid-, and postinfusions (interquartile range [IQR]) were 2.4 (1.8-3.2), 4.2 (3.5-6), and 4 (3.4-5.3), respectively. The median fluid balance (mL; IQR) was 189 (90-526), -258 (-411.7 to 249) and -113.5 (-212.5 to 80.2), respectively. There were statistically significant differences in UOP and fluid balance pre- versus mid-therapy (0.014) and pre- versus posttherapy (p=0.010). No significant differences were noted with magnesium and potassium. Five children (55.6%) developed metabolic alkalosis. CONCLUSIONS: This study provides preliminary evidence for ethacrynic acid CI in children. The median initial dose and maximum dose in this cohort were 0.13 mg/kg/hr and 0.17 mg/kg/hr, respectively. Larger prospective studies are needed to confirm these findings.

Functional lengths of the lower limb arterial tree measured by CT angiography centreline analysis: implications for catheter lengths in peripheral angioplasty.

PURPOSE: Lower limb angioplasty is a common procedure. However, arterial lengths have not been well studied and there is no evidence base for the optimum catheter lengths required for the various applications of femoral or distal below-the-knee angioplasty. The industry standard catheter measures 80 cm. METHOD: Fifty CT angiograms were post-processed using vessel tracking and centreline analysis tools and lengths were measured from the ipsilateral first segment of the femoral artery (FSFA) (common femoral artery) to the contralateral FSFA and on to the second segment of the femoral artery (superficial femoral artery) and popliteal arteries down to the posterior tibial (PT) artery at the ankle. This allowed clinically meaningful lengths for 'cross-over' and 'antegrade' angioplasty to be calculated. RESULTS: Mean cross-over length to the second segment of the femoral artery as it crossed the femoral cortex was 72.3 cm, and the mean cross-over length to the popliteal artery at the knee joint was 83.8 cm, and the length from the FSFA to the PT was 85.1 cm. CONCLUSION: Selection of a standard length catheter can result in a situation where the catheter is too short. Optimum catheter length for a particular task will reduce the need for catheter exchanges and use of multiple balloons and therefore reduce complications, procedure time, radiation dose and cost.

Strategies for prevention of iatrogenic inferior vena cava filter entrapment and dislodgement during central venous catheter placement.

BACKGROUND: Iatrogenic migration of inferior vena cava (IVC) filters is a potentially life-threatening complication that can arise during blind insertion of central venous catheters when the guide wire becomes entangled with the filter. In this study, we reviewed the occurrence of iatrogenic migration of IVC filters in the literature and assessed methods for preventing this complication. METHODS: A literature search was conducted to identify reports of filter/wire entrapment and subsequent IVC filter migration. Clinical outcomes and complications were identified. RESULTS: A total of 38 cases of filter/wire entrapment were identified. All of these cases involved J-tip guide wires. Filters included 23 Greenfield filters, 14 VenaTech filters, and one TrapEase filter. In 18 cases of filter/wire entrapment, there was migration of the filter to the heart and other central venous structures. Retrieval of the migrated filter was successful in only four of the 18 cases, and all of these cases were complicated by strut fracture and distant embolization of fragments. One patient required resuscitation during retrieval. Successful disengagement was possible in 20 cases without filter migration. CONCLUSIONS: Iatrogenic migration of an IVC filter is an uncommon complication related to wire/filter entrapment. This complication can be prevented with knowledge of the patient's history, use of proper techniques when placing a central venous catheter, identification of wire entrapment at an early stage, and use of an appropriate technique to disengage an entrapped wire.

3D printing of an aortic aneurysm to facilitate decision making and device selection for endovascular aneurysm repair in complex neck anatomy.

PURPOSE: To describe rapid prototyping or 3-dimensional (3D) printing of aneurysms with complex neck anatomy to facilitate endovascular aneurysm repair (EVAR). CASE REPORT: A 75-year-old man had a 6.6-cm infrarenal aortic aneurysm that appeared on computed tomographic angiography to have a sharp neck angulation of ~90°. However, although the computed tomography (CT) data were analyzed using centerline of flow, the true neck length and relations of the ostial origins were difficult to determine. No multidisciplinary consensus could be reached as to which stent-graft to use owing to these borderline features of the neck anatomy. Based on past experience with rapid prototyping technology, a decision was taken to print a model of the aneurysm to aid in visualization of the neck anatomy. The CT data were segmented, processed, and converted into a stereolithographic format representing the lumen as a 3D volume, from which a full-sized replica was printed within 24 hours. The model demonstrated that the neck was adequate for stent-graft repair using the Aorfix device. CONCLUSION: Rapid prototyping of aortic aneurysms is feasible and can aid decision making and device delivery. Further work is required to test the value of 3D replicas in planning procedures and their impact on procedure time, radiation dose, and procedure cost.

Gelfoam-assisted amplatzer vascular plug technique for rapid occlusion in proximal splenic artery embolization.

OBJECTIVE: The objective of this study was to prospectively investigate the role of rapid Gelfoam-assisted occlusion of the splenic artery with an Amplatzer Vascular Plug (AVP). Ten consecutive proximal splenic artery embolizations were performed with AVP as the primary embolic agent and Gelfoam slurry as an adjunct. These cases were then compared with 10 retrospective cases of splenic artery embolization performed with AVP and augmented with coils or additional AVPs, or both, in patients with similar indications. CONCLUSION: Successful proximal splenic artery embolization using a single Amplatzer Vascular Plug and Gelfoam slurry occurred in all cases. No recanalization was identified on imaging follow-up at an average interval of 5.1 months. Gelfoam can be used as an adjunct to AVP in proximal splenic artery embolization. Using adjunctive Gelfoam is a simple, safe, and cost-saving method of improving the occlusion efficiency of the Amplatzer Vascular Plug.

3-D printouts of the tracheobronchial tree generated from CT images as an aid to management in a case of tracheobronchial chondromalacia caused by relapsing polychondritis.

This report concerns a 67 year old male patient with known advanced relapsing polychondritis complicated by tracheobronchial chondromalacia who is increasingly symptomatic and therapeutic options such as tracheostomy and stenting procedures are being considered. The DICOM files from the patient's dynamic chest CT in its inspiratory and expiratory phases were used to generate stereolithography (STL) files and hence print out 3-D models of the patient's trachea and central airways. The 4 full-sized models allowed better understanding of the extent and location of any stenosis or malacic change and should aid any planned future stenting procedures. The future possibility of using the models as scaffolding to generate a new cartilaginous upper airway using regenerative medical techniques is also discussed.

The urge to merge.

For many stand-alone hospitals, a merger, partnership, or affiliation may be the only option to access scale and remain viable in the nation's emerging new healthcare delivery system. These organizations can consider many options for affiliation, including traditional options such as affiliation with regional academic medical centers, a merger or takeover to become the corporate member of a large system, and acquisition by a for-profit system. Emerging options include mergers for scale and access to capital, private-equity transactions, and arrangements involving insurance vertical integration.

3-D printout of a DICOM file to aid surgical planning in a 6 year old patient with a large scapular osteochondroma complicating congenital diaphyseal aclasia.

A 6 year old girl presented with a large osteochondroma arising from the scapula. Radiographs, CT and MRI were performed to assess the lesion and to determine whether the lesion could be safely resected. A model of the scapula was created by post-processing the DICOM file and using a 3-D printer. The CT images were segmented and the images were then manually edited using a graphics tablet, and then an STL-file was generated and a 3-D plaster model printed. The model allowed better anatomical understanding of the lesion and helped plan surgical management.