Surgical Anatomy of Transversus Abdominis Muscle for Transversus Abdominis Release: A CT-Based Study in Three Patient Groups.

BACKGROUND: The anatomy of the transversus abdominis muscle and its aponeurosis is important in transversus abdominis release surgery. We studied the CT anatomy of the transversus abdominis muscle medial to the linea semilunaris at different levels in the abdomen and measured the thickness of this muscle. METHODS: In this retrospective study, we analysed 150 abdominal computed tomography at L1, L3, and L5 vertebral levels corresponding to subxiphoid, umbilical, and suprapubic regions, respectively. The patients were divided into three groups based on age and sex: women aged 15-20 years (nulliparous), women aged 30-60 years (multiparous), and men aged 15-60 years, with each group having 50 patients. We compared the thickness of the TA muscle at the L1 level between men and women and between nulliparous and multiparous women. RESULTS: Transversus abdominis muscle was consistently present medial to the linea semilunaris at L1 vertebral level in the subxiphoid region (150/150). At the L3 vertebral level in the mid-abdomen, only eight patients had the transversus abdominis muscle there (8/150, 5%). At the L5 vertebral level in the suprapubic region, no patient had the transversus abdominis muscle medial to the linea semilunaris. The mean thickness of the transversus abdominis muscle at the L1 level was 3.4 mm, and at the L3 level, it was 1.6 mm. There was no statistically significant difference in the transversus abdominis muscle thickness between the men and women; however, a significant difference was found between the nulliparous and multiparous women, with thinner TA muscle in later. CONCLUSION: There is good transversus abdominis muscle bulk medial to the linea semilunaris for doing transversus abdominis muscle division in the upper abdomen. However, as we move towards the mid-abdomen, we have TA aponeurosis or rarely TA muscle of little bulk.

Dentition status among an ethnically diverse older urban Malaysian population.

BACKGROUND: Poor oral health affects not only dietary choices but overall well-being. This study explores the influence of lifestyle, socio-demographics and utilization of dental services on the dentition status of an older urban Malaysian population. METHODS: A total of 1210 participants 60 years and above, representing the three main ethnic groups were recruited from a larger cohort study. Weighted factors valued for comparison included socio demographics and health status. Knowledge of and attitude and behaviour towards personal oral health were also assessed. Dentition status, adapted from WHO oral health guidelines, was the dependent variable investigated. Data were analysed using descriptive chi square test and multivariate binary logistic regression. RESULTS: Overall, 1187 respondents completed the study. The dentition status and oral health related knowledge, attitude and behaviour varied between the three ethnic groups. The Chinese were significantly less likely to have ≥13 missing teeth (OR = 0.698, 95% CI: 0.521-0.937) and ≥1 decayed teeth (0.653; 0.519-0.932) compared to the Malays, while the Indians were significantly less likely than the Malays to have ≥1 decayed teeth (0.695; 0.519-0.932) and ≥2 filled teeth (0.781; 0.540-1.128). CONCLUSION: Ethnic differences in dentition outcome are related to oral health utilization highlighting the influence of cultural differences and the need for culturally sensitivity interventions.

A Standardized Ultrasound Scoring System for Preoperative Prediction of Difficult Laparoscopic Cholecystectomy.

PURPOSE: Laparoscopic cholecystectomy (LC) has become the treatment of choice for cholelithiasis. Still some patients required conversion to open cholecystectomy (OC). Our aim was to develop a standardized Ultrasound based scoring system for preoperative prediction of difficult LC. METHODS AND MATERIALS: Ultrasound findings of 300 patients who underwent LC were reviewed retrospectively. Four parameters (time taken, biliary leakage, duct or arterial injury, and conversion) were analyzed to classify LC as easy or difficult. The following ultrasound findings were analyzed: GB wall thickness, pericholecystic collection, distended GB, impacted stones, multiple stones, CBD diameter and liver size. Out of seven parameters, four were statistically significant in our study. A score of 2 was assigned for the presence of each significant finding and a score of 1 was assigned for the remaining parameters to a total score of 11. A cut-off value of 5 was taken to predict easy and difficult LC. RESULTS: 66 out of 83 cases of difficult LC and 199 out of 217 cases of easy LC were correctly predicted on the basis of scoring system. A score of >5 had sensitivity 80.7% and specificity 91.7% for correctly identifying difficult LC. Prediction came true in 78.8% difficult and 92.6% easy cases. US findings of GB wall thickness, distended GB, impacted stones and dilated CBD were found statistically significant. CONCLUSION: This indigenous scoring system is effective in predicting conversion risk of LC to OC. Patients having high risk may be informed and scheduled appropriately and decision to convert to OC in case of anticipated difficulty may be taken earlier.

Clinical examination vs. MRI: evaluation of diagnostic accuracy in detecting ACL and meniscal injuries in comparison to arthroscopy.

BACKGROUND: To compare the diagnostic accuracy of clinical examination and MRI in evaluation of meniscal and ACL injuries using arthroscopic findings as reference standard. MATERIAL/METHODS: A total of 51 patients with traumatic knee injuries were identified and prospectively followed up with clinical examination, MRI and arthroscopy. Clinical examination and MRI findings were compared with arthroscopic findings. Sensitivity, specificity, PPV, NPV and diagnostic accuracy were calculated with statistical analysis. RESULTS: Out of 24 patients with arthroscopic evidence of medial meniscal injury, clinical examination and MRI correctly identified 20 and 18 patients, respectively. Clinical examination was characterized by better sensitivity and specificity with regard to diagnosis of medial meniscal tear. On arthroscopy, lateral meniscal tear was present in 13 patients; clinical examination and MRI both identified 8 of them correctly. Similarly, out of 9 patients with arthroscopic evidence of ACL tear, clinical examination and MRI correctly identified 7 and 8 patients, respectively. There were only marginal differences in sensitivity and specificity of clinical examination and MRI in diagnosis of lateral meniscal and ACL injury. CONCLUSIONS: Careful clinical examination is much better than MRI with regard to the diagnosis of medial meniscus injury and is as reliable as MRI with regard to diagnosis of lateral meniscus injury and ACL tears. MRI should be used to rule out such injuries rather than to diagnose them.

Painless left hemorrhagic pleural effusion: an unusual presentation of leaking saccular aortic arch aneurysm.

Most thoracic aortic aneurysms are asymptomatic and are detected by chance on routine chest imaging for some other reasons. Only rarely it is symptomatic due to leak and dissection which is a potentially life threatening event that commonly presents with severe pain. In this report, we present the case of a 67-year-old man who presented with shortness of breath, intermittent cough, fever, and left sided painless hemorrhagic pleural effusion. Further investigation by plain radiography, computed tomography and magnetic resonance imaging revealed a saccular aneurysm arising from the lateral aspect of the mid-transverse arch of the aorta, along with a dissecting descending aortic aneurysm with false lumen communicating with left pleural space. The patient refused any surgical procedure and was treated conservatively with blood transfusions and anti hypertensive medication. On the 8th day patient finally succumb to a fatal episode of shock. We suggest dissecting thoracic aneurysm be included in the differential diagnosis of non-traumatic hemorrhagic pleural effusion in an elderly patient presenting with dysnea, cough and fever, which otherwise suggest the clinical diagnosis of bronchogenic carcinoma. Computed tomography of the chest should be immediately performed as the diagnostic procedure of choice.

Risk factors influencing postoperative outcome in patients with perforated peptic ulcer: a prospective cohort study.

BACKGROUND: Perforated peptic ulcer (PPU) has been associated with substantially high incidence of morbidity and mortality. The aim of this study was to analyze the factors affecting the outcome of patients having perforated peptic ulcer undergoing surgical intervention. MATERIALS AND METHODS: Medical records of 112 patients with PPU who underwent emergency laparotomy between December 2014 and November 2016 were prospectively analyzed. Primary suture of the perforation and pedicled omentoplasty was done in all the patients. Data regarding patients was collected and correlated with the postoperative outcome. RESULTS: The overall postoperative morbidity and mortality were 62.5% and 30.4%, respectively. On univariate analysis advanced age (≥ 60 years) [(p = 0.005), (OR = 3.6), (95% CI = 1.5-8.8)], pre-operative shock [(p < 0.001), (OR = 7.4), (95% CI = 2.6-21.0)], delayed presentation (> 24 h) [(p = 0.007), (OR = 4.0), (95% CI = 1.5-11.2)] and raised serum creatinine [(p < 0.001), (OR = 7.7), (95% CI = 3.1-19.0)] were found to be significantly associated with the post-operative morbidity. For mortality, advanced age (≥ 60 year) [(p < 0.001), (OR = 5.02), (95% CI = 2.1-11.9)], pre-operative shock [(p < 0.001), (OR = 19.3), (95% CI = 6.9-53.6)], comorbidity [(p = 0.03), (OR = 6.6), (95% CI = 1.2-35.7)] and raised serum creatinine [(p < 0.001), (OR = 13.1), (95% CI = 4.5-37.8)] were statistically significant factors. Multivariate analysis showed advanced age (≥ 60 years) (p = 0.05) and raised serum creatinine (p = 0.004) as significant factors for increased risk of post-operative morbidity. Advanced age (≥ 60 years), pre-operative shock and raised serum creatinine were found to be independent risk factors influencing post-operative mortality (p < 0.05). CONCLUSION: A thorough clinical evaluation, adequate resuscitation, sepsis control, addressing comorbidities and early access to hospital can reduce the risk morbidity and mortality in patients with PPU.

Chromium toxicity, speciation, and remediation strategies in soil-plant interface: A critical review.

In recent decades, environmental pollution with chromium (Cr) has gained significant attention. Although chromium (Cr) can exist in a variety of different oxidation states and is a polyvalent element, only trivalent chromium [Cr(III)] and hexavalent chromium [Cr(VI)] are found frequently in the natural environment. In the current review, we summarize the biogeochemical procedures that regulate Cr(VI) mobilization, accumulation, bioavailability, toxicity in soils, and probable risks to ecosystem are also highlighted. Plants growing in Cr(VI)-contaminated soils show reduced growth and development with lower agricultural production and quality. Furthermore, Cr(VI) exposure causes oxidative stress due to the production of free radicals which modifies plant morpho-physiological and biochemical processes at tissue and cellular levels. However, plants may develop extensive cellular and physiological defensive mechanisms in response to Cr(VI) toxicity to ensure their survival. To cope with Cr(VI) toxicity, plants either avoid absorbing Cr(VI) from the soil or turn on the detoxifying mechanism, which involves producing antioxidants (both enzymatic and non-enzymatic) for scavenging of reactive oxygen species (ROS). Moreover, this review also highlights recent knowledge of remediation approaches i.e., bioremediation/phytoremediation, or remediation by using microbes exogenous use of organic amendments (biochar, manure, and compost), and nano-remediation supplements, which significantly remediate Cr(VI)-contaminated soil/water and lessen possible health and environmental challenges. Future research needs and knowledge gaps are also covered. The review's observations should aid in the development of creative and useful methods for limiting Cr(VI) bioavailability, toxicity and sustainably managing Cr(VI)-polluted soils/water, by clear understanding of mechanistic basis of Cr(VI) toxicity, signaling pathways, and tolerance mechanisms; hence reducing its hazards to the environment.

Persistent port-site sinus in a patient after laparoscopic cholecystectomy: watch out for gallbladder tuberculosis.

BACKGROUND: The gallbladder is rarely affected by mycobacterium tuberculosis. The diagnosis of gallbladder tuberculosis is often not suspected prior to surgery or biopsy. METHOD: A young female patient underwent laparoscopic cholecystectomy but presented with a persistently discharging sinus from the port site. RESULTS: The gallbladder biopsy revealed granulomas typical of chronic granulomatous tuberculosis. The condition of the patient was improved by antitubercular treatment. CONCLUSIONS: Presentation of gallbladder tuberculosis as a persistent discharging sinus at the port site in a patient who has undergone a laparoscopic cholecystectomy is extremely rare. The diagnosis was reached by histopathology only. The rarity of the presentation prompted us to report the case.

Preventive Practices of Ophthalmologists During COVID-19 Pandemic.

PURPOSE: To explore ophthalmologists' preventive practices, and their perceived seriousness and perceived risk of transmission of coronavirus disease 2019 (COVID-19). METHODS: In a cross-sectional study, a semi-structured questionnaire was distributed online among ophthalmologists. Questions about COVID-19 infection, perceived seriousness, perceived risk of transmission, and recommended COVID-19 preventive practices were asked. Based on the adoption of a preventive measure and its frequency, a maximum preventive score of 25 was computed. RESULTS: Among 126 respondents, the mean±SD age was 45.3±10.9 years, and 57.9% worked in a tertiary care hospital. Regarding preventive practices, 96.8% of ophthalmologists wore face masks, 89.6% avoided talking during the slit lamp examination, and 72.2% wore gloves during the ophthalmic examination. Availability of plastic barriers and regular disinfection of slit lamps were reported by 78.6% and 43.7% of ophthalmologists, respectively. The mean preventive score increased with increasing age (p=0.001), and was higher for males (18.96±4.60) compared to females (17.81±4.96). The mean score for perceived severity was higher (p<0.0001) among ophthalmologists with more than 10 years of experience (8.76±1.58) than those with experience of 10 years or less (7.49±1.86). Out of 29 ophthalmologists who had been tested for COVID-19, 11 were found to be positive, giving an overall incidence of COVID-19 infection of 8.7%. CONCLUSION: The ophthalmologists were generally compliant with recommended preventive measures. Some preventive measures, such as the wearing of gloves and regular disinfection of slit lamps, need improvement. We recommend creating awareness of and monitoring for COVID-19 infection control measures in healthcare settings.

Frequency Of Developmentally Malformed Permanent Maxillary Lateral Incisors In Patients Visiting The Three Teaching Dental Hospitals Of Peshawar.

BACKGROUND: The permanent maxillary lateral incisor (PMLI) shows morphological variations, in the form of different crown shapes such as peg-shaped, cone-shaped, barrel-shaped and canine-shaped. The frequency of developmentally malformed permanent maxillary lateral incisors varies among different populations. The aim of this study was to document the frequency of different shapes of developmentally malformed permanent maxillary lateral incisors in patients visiting the three teaching dental hospitals of Peshawar. METHODS: It was a cross-sectional study conducted in the Oral Diagnosis department of Peshawar Dental College, Sardar Begum Dental College, and Khyber College of Dentistry from 1st Sep 2018 to 15th June 2019. A total of 82 subjects were included that fulfilled the inclusion criteria. Shape of the malformed PMLI was determined using Computer-aided design/Computer-aided manufacturing software. Descriptive statistics including frequencies and percentages for observed developmental malformation and their types were computed and Chi-square test was applied to see the relation between various shapes and their occurrence with respect to site and position within the jaws. RESULTS: The peg shaped PMLI was seen in 81 (98.87%) patients and barrel shaped was present in 1 (1.22%) patient. The malformed PMLIs was found to be unilateral in 38 (46.3%) and bilateral in 44 (53.7%) patients, with more common presence on both sides 44 (53.7%) followed by right side 20 (24.4%) and left side 18 (22.0%). CONCLUSIONS: The subjects having predominant developmental malformation in case of permanent maxillary lateral incisor was peg-shaped permanent maxillary lateral incisor.

Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.

Hydatid disease is endemic in regions where livestock is raised. Liver and lungs are the most commonly affected organs by the disease. Cranial vault and orbital hydatid disease is extremely rare. Signs and symptoms along with serological investigation are often inconclusive in cranial hydatid, making radiological diagnosis extremely important. Surgical removal of the cyst is the mainstay of treatment. Postoperative medical therapy, along with regular follow-up, is the key to detect any recurrence. We report an unusual case of cranial hydatid which showed diffuse scalp infiltration along with orbital and extradural extension.

Conventional Laparoscopic Appendectomy Versus Single-Port Laparoscopic Appendectomy, a Multicenter Randomized Control Trial: A Feasible and Safe Alternative to Standard Laparoscopy.

Background: Acute appendicitis represents one of the main causes of surgical emergencies. It can be approached as open appendectomy or laparoscopic appendectomy (LA). LA uses different modalities, such as conventional laparoscopic appendectomy (CLA) or single-port laparoscopic appendectomy (SPLA). The aim of this work is to compare the results of CLA versus SPLA in patients diagnosed with Acute Appendicitis. Materials and Methods: A comparative multicenter prospective study of patients undergoing LA with a clinical diagnosis of acute appendicitis was presented. They were divided into two groups (CLA group and SPLA group). Results: A total of n = 147 patients were included (72 CLA and 75 SPLA). Preoperative and intraoperative times were shorter for patients undergoing CLA (P = .002; P = .068). Postoperative and reinsertion time was lower for SPLA (P = .000; P = .0004). There were no differences in postoperative complications. The type of approach showed statistically significant differences with respect to pain within the first 12 hours of the postoperative period, as well as at discharge, while no differences were observed in relation to cosmetic satisfaction when the two approaches were compared. Conclusion: SPLA technique presented less intraoperative time, shorter time of labor reinsertion, and less postoperative pain. There were no statistically significant differences in postoperative complications.

Effects of limb electrode placement on the 12- and 16-lead electrocardiogram.

The effects of three common limb electrode placement configurations on ECG signal morphology were examined, including the standard electrode placement of the electrodes on the extremities, the Mason-Likar placement, and the Lund placement. A non-traditional asymmetric configuration of placing the LA electrode on the upper arm with the RA electrode on the torso (below the clavicle) was also investigated. A series of 16-lead ECGs were acquired from 150 subjects representing a broad range of diseases. Effects of the limb electrode placement on axis measurements, QRS amplitudes, ST levels, and infarctions were studied. On average, the P, QRS, and T axes all exhibited rightward shifts as the electrodes were moved away from the extremities, but more generally, the axis became more vertical, with the largest shifts occurring when the standard ECG axis measurement was close to 0 degrees and tending to exhibit leftward shifts for ECGs with a standard axis measurement between 0 and -90 degrees. Voltage changes were consistent with axis shifts in the frontal plane (decreased lateral and increased inferior lead voltages), with the largest mean change a reduction in R wave amplitude of lead I going from the standard to the Mason-Likar configuration. In the precordial leads, Q and/or S magnitudes decreased in right-sided leads (V4r, V1, V2, V3) and R magnitudes increased in lateral leads (V3-V9) as the arm electrodes moved toward the trunk, suggesting a posterior shift in the mean QRS axis. ST deviations in the lateral and posterior precordial leads tended to be mimicked in lead III when the electrodes were moved from the extremities to the torso. Over half (13 of 25) of the ECGs exhibiting criteria for inferior infarct in the standard configuration had that criteria erased when the electrodes were moved to the Mason-Likar positions. The largest single effect on the ECG resulted from moving the LA electrode from the shoulder to the clavicle. The asymmetric configuration with the RA electrode on the torso and the LA electrode on the upper arm may offer some compromise between noise and faithfulness to the standard configuration in noisy environments such as exercise testing or monitoring.

Evaluation of results of interlocking nails in femur fractures due to high velocity gunshot injuries.

BACKGROUND: Femoral shaft fractures are common in adult population due to vulnerability to road traffic accident and firearm injuries. There are various treatment modalities to treat the femur shaft fracture, i.e., Plating & screws, Intramedullary nailing, External fixator and Interlocking nails. Comminuted fractures due to gun shot injuries are a challenging problem for orthopaedic surgeons. The objective of this study is to evaluate the role of interlocking nailing in the management of femoral fractures due to high velocity gunshot injuries. METHODS: This descriptive study was conducted on 68 patients at Orthopaedic unit Postgraduate Medical Institute, Lady Reading Hospital Peshawar, from March 2002 to March 2004. The patients of each gender from age fifteen years onward having femoral shaft fracture due to high velocity gunshot injuries who had not previous surgical intervention were included in the study. The exclusion criteria were intertrochanteric, supracondylar femoral fractures and those who failed the follow-up. All the patients were treated with close or open interlocking nails. The outcome measures were graded excellent, good and poor according to radiological and clinical results. Follow-up was for eighteen months and in some cases up to thirty months. RESULTS: Out of 68 patients 64 (94.12%) were male and 4 (5.88%) were female patients. The age range was from 15 to 65 years (average age of twenty nine years. The close interlocking nails were done in 64 patients (94.12%) and open interlocking nails were done in 4 patients (5.88%). The static interlocking nailing was performed in 58 patients (85.29%) while dynamic interlocking nailing was performed in 10 patients (14.71%). Knee flexion contracture in 5 cases (7.35%) and limb shortening of less than 2 Cm in 2 patients (2.94%). Non-union were in 4 cases (5.88%). Excellent results were in 42 patients (61.76%), good in 18 patients (26.47%) and poor in 8 patients (11.77%). CONCLUSION: Interlocking nailing is one of the best options for the management of femoral shaft fractures due to high velocity gunshot injuries.

Modified Turco's postero-medial release for congenital talipes equino-varus.

BACKGROUND: Talipes Equino-Varus (TEV) is one of the most common congenital anomaly. It is managed by various methods, i.e., conservative & surgery. Objective of this study was to determine the efficacy of modified Turco's postero-medical release in children's having congenital TEV. METHODS: This descriptive observational study was conducted from June 2004 to June 2008 in the Orthopaedics Unit of Lady Reading Hospital (LRH) Peshawar. The inclusion criteria were children of age 6 months to 3 years of age having moderate and severe club foot. The exclusion criteria were clubfoot secondary to some other disorders such as cerebral palsy, arthrogryphosis multiplex congenita, myelodysplasia or congenital dislocation of the hip. The deformity was treated by modified Turco's one stage release. Follow-up was for one year. Results were graded according to modified McKay rating system. RESULTS: A total 70 patients were included in this study with the age range of 6 months to 3 years with moderate to sever deformity. Thirty-eight, were male (54.2%) and 32 patients (45.72%) were female, twenty three patients (32.85%) had bilateral club foot while the rest of 47 patients (67.15%) had unilateral deformity. Positive family history of club foot was in 10 patients (14.2%). Results were concluded on 52 patients who completed one year follow-up. Excellent results were observed in 34 patients (65.38%), good in 9 patients (17.30%), fair in 2 patients (3.84%), and poor in 7 patients (13.46%). CONCLUSION: Children up to three years age with congenital TEV can be successfully treated in almost all the cases by modified Turco's one stage postero-medial release.

Ten-Year Experience of Managing Giant Duodenal Ulcer Perforations with Triple Tube Ostomy at Tertiary Hospital of North India.

Duodenal ulcer perforations have been known since 1600 AD. It is a common surgical emergency and every surgeon will encounter it. The perforation size of >2 cm has been used as the criteria for defining Giant duodenal ulcers. The management of giant duodenal perforations in hemodynamically unstable patient with comorbid condition is taxing because of high incidence of the postoperative leak and mortality. We have used the simple technique of Triple Tube Ostomy after the primary closure of the defect with encouraging results. It is a retrospective study done at the J. N medical college AMU Aligarh from May 2005 to May 2015. Hemodynamically unstable patients who have presented to the emergency with preoperative diagnoses of giant duodenal ulcer perforation and had undergone triple tube ostomy with primary repair of the perforation were included in the study. There were 34 patients of giant duodenal perforation who presented in shock. All of them underwent triple-tube-ostomy after primary repair of the duodenum. Thirty-two patients recovered with two mortalities (5.8 %). Several definite surgical techniques have been described for the management of giant duodenal ulcer perforation but they are complex, have very high morbidity and mortality rate and require an expert surgeon. A close retrospective scrutiny of the patients suggests that simple triple-tube-ostomy technique which is based on the principle of damage control surgery has good postoperative results Therefore, we recommend it as the procedure of choice in these patients.

Immunocompetence of the severely injured spleen verified by differential interference contrast microscopy: the red blood cell pit test.

OBJECTIVE: To determine the immunocompetence of the successfully nonoperatively managed injured spleen warranting vaccinations for overwhelming postsplenectomy sepsis by differential interference contrast microscopy (DICM). METHODS: Cull an urban Level I trauma systems data bank for all patients with grade IV or V splenic injuries (those with the greatest potential to compromise immunologic function) successfully managed nonoperatively and those who have required splenectomies since 1996 and verify the Association for the Surgery of Trauma grading. Contact or obtain written consent of these patients and acquire a blood sample for DICM (red blood cell [RBC] pit analysis) and IgM levels (as a control). Compare values of those sustaining splenic injuries with those of two control groups: patients with splenectomies and those with normal splenic function. RESULTS: Forty patients were contacted, consented, and volunteered blood samples: 10 patients with grade IV splenic injuries, 1 patient with a grade V injury, 14 patients with splenectomies, and 15 controls. Average RBC pit levels and IgM levels for patients sustaining injuries (15) and successfully nonoperatively managed were 0.6% (0%-2% nL) and 91 mg/dL (46-304 nL), respectively. Patients with splenectomies had levels of 20.4% and 86 mg/dL whereas controls had levels of 0.7% and 110 mg/dL, respectively. The average time frame from injury to RBC pit test was 3.1 years. Comparing the successfully nonoperatively managed group with the splenectomy group using t test with Satterthwaite's method because of unequal variances, there was a statistically significant difference (p = 0.0002). Comparing the same study group with those with normal splenic function using t test with pooled variance, there was no statistical significant difference between groups (p = 0.489). CONCLUSION: DICM, a commonly used test to evaluate splenic-based immunocompetence in patients with sickle cell anemia, hemoglobinopathies, and patients undergoing partial splenectomies, also confirms splenic immunocompetence in patients sustaining up to grade IV splenic injuries. IgM levels earlier thought to be low in patients after splenectomy normalize.

Transcatheter Aortic Valve Replacement Versus Aortic Valve Bypass: A Comparison of Outcomes and Economics.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is currently offered to patients who are high-risk candidates for conventional surgical aortic valve replacement. For the past 37 years, off-pump aortic valve bypass (AVB) has been used in elderly patients at our center for this similarly high-risk group. Although TAVR and AVB were offered to similar patients at our center, comparisons of clinical outcomes and hospital economics for each strategy were not reported. METHODS: We reviewed the clinical and financial records of 53 consecutive AVB procedures performed since 2008 with the records of 51 consecutive TAVR procedures performed since 2012. Data included demographics, hemodynamics, The Society of Thoracic Surgeons (STS) risk score, extent of coronary disease, and ventricular function. Follow-up was 100% in both groups. Hospital financial information for both cohorts was obtained. Mean risk score for the TAVR group was 10.1% versus 17.6% for AVB group (p < 0.001). RESULTS: Kaplan-Meier hospital rates of 3- and 6-month survival and of 1-year survival were 88%, 86%, 81%, and 61% and 89%, 83%, 83%, and 70% for the TAVR and AVB groups, respectively (p = 0.781). Two patients who had undergone TAVR had a procedure-related stroke. The one stroke in an AVB recipient was late and not procedure related. At discharge, mild and moderate perivalvular and central aortic insufficiency were present in 31% and 16% of TAVR recipients, respectively; no AVB valve leaked. Transvalvular gradients were reduced to less than 10 mm Hg in both groups. The average hospital length of stay for the AVB-treated patients was 13 days, and it was 9 days for the TAVR-treated patients. Median hospital charges were $253,000 for TAVR and $158,000 for AVB. Mean payment to the hospital was $65,000 (TAVR) versus $64,000 (AVB), and the mean positive contribution margin (profit) to the hospital was $14,000 for TAVR versus $29,000 for AVB. CONCLUSIONS: TAVR and AVB relieve aortic stenosis and have similar and acceptable procedural mortality rates. AVB-treated patients had 1.75 times the STS risk score when compared with the TAVR cohort. Hospital charges for TAVR were nearly twofold those of AVB. Hospital reimbursement was similar, but AVB had two to four times the profit margin of TAVR. Longer follow-up for the TAVR cohort will determine whether survival is comparable to that after AVB at 3 and 5 years.

Transcatheter Aortic Valve Replacement: Current Technology and Future Directions.

Transcatheter aortic valve replacement as an alternative to open surgical repair is rapidly becoming more used in high-risk patients with aortic stenosis. Transcatheter aortic valve replacement offers the benefit of being much less invasive than traditional surgical repair and has evolved as a therapeutic option for patients with prohibitive surgical risk or those deemed surgically inoperable. Nevertheless, despite its potential to mitigate risk in this frail population, it comes with its own unique set of complications. Technological advancements in valve structure, function, and delivery have and continue to attempt to minimize these risks. This review aims to summarize current advancements in transcatheter aortic valve replacement technology while also introducing areas of future direction in this exciting new field.

Transcatheter Aortic Valve Replacement Results in Improvement of Pulmonary Function in Patients With Severe Aortic Stenosis.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has been identified as a risk factor for morbidity and mortality after transcatheter aortic valve replacement (TAVR). We hypothesized that a portion of pulmonary dysfunction in patients with severe aortic stenosis may be of cardiac origin, and has potential to improve after TAVR. METHODS: A retrospective analysis was made of consecutive TAVR patients from April 2008 to October 2014. Of patients who had pulmonary function testing and serum B-type natriuretic peptide data available before and after TAVR, 58 were found to have COPD (26 mild, 14 moderate, and 18 severe). Baseline variables and operative outcomes were explored along with changes in pulmonary function. Multiple regression analyses were performed to adjust for preoperative left ventricular ejection fraction and glomerular filtration rate. RESULTS: Comparison of pulmonary function testing before and after the procedure among all COPD categories showed a 10% improvement in forced vital capacity (95% confidence interval: 4% to 17%) and a 12% improvement in forced expiratory volume in 1 second (95% confidence interval: 6% to 19%). There was a 29% decrease in B-type natriuretic peptide after TAVR (95% confidence interval: -40% to -16%). An improvement of at least one COPD severity category was observed in 27% of patients with mild COPD, 64% of patients with moderate COPD, and 50% of patients with severe COPD. There was no 30-day mortality in any patient group. CONCLUSIONS: In patients with severe aortic stenosis, TAVR is associated with a significant improvement of pulmonary function and B-type natriuretic peptide. After TAVR, the reduction in COPD severity was most evident in patients with moderate and severe pulmonary dysfunction.