Stroke and mortality rates after off-pump vs. pump-assisted/no-clamp coronary artery bypass grafting.

BACKGROUND: Ascending aorta manipulation during on-pump coronary artery bypass grafting (CABG) surgery can release embolic matter and may cause stroke. Strategies for lowering the stroke rate associated with coronary artery bypass grafting surgery include off-pump surgery without cardiopulmonary bypass and pump-assisted surgery with minimal aortic manipulation (i.e., without aortic cross-clamping). We examined whether one approach is superior to the other in reducing stroke and perioperative mortality rates. METHODS: We reviewed consecutive elective, urgent, and emergency off-pump/no-bypass and pump-assisted/no-clamp coronary artery bypass grafting procedures performed by a single surgeon at our institution from June 2011 through October 2017. RESULTS: Of 570 patients analyzed, 395 (69.3%) underwent off-pump/no-bypass surgery, 43 (7.5%) underwent pump-assisted/no-clamp surgery, and 132 (23.2%) transitioned mid-procedure from off-pump/no-bypass to pump-assisted/no-clamp surgery. Patients who were >70 years old, were female, or had diabetes, cardiomegaly, or a history of myocardial infarction or congestive heart failure were more likely to undergo pump-assisted/no-clamp surgery or the combined technique. None of the pump-assisted/no-clamp patients had a stroke, versus 0.3% of the off-pump/no-bypass patients and 0.8% of the combination patients. Stroke and in-hospital mortality rates did not differ by technique. CONCLUSIONS: A hybrid strategy incorporating off-pump, pump-assisted, and combined off-pump/pump-assisted techniques achieved very low stroke rates in patients undergoing coronary revascularization. Perioperative mortality was similar for all three techniques. Avoiding aortic clamping may be crucial for decreasing CABG-related stroke rates. Off-pump/no-bypass surgery had no significant advantage over the pump-assisted/no-clamp or combined techniques in reducing the stroke rate after coronary artery bypass grafting surgery.

Effect of Caudal vs. Penile Block on the Incidence of Hypospadias Complications Following Primary Repairs: A Retrospective Cohort Study.

PURPOSE: Primary repair of hypospadias is associated with risk of complications, specifically urethrocutaneous fistula and glanular dehiscence. Caudal block may potentially increase the risk of these complications. Therefore, we studied the incidence of hypospadias complications in children who underwent correction at our institution having received either penile or caudal block. MATERIALS AND METHODS: We analyzed all primary hypospadias repair cases from December 2011 through December 2018 at Texas Children's Hospital with a minimum of 1-year followup for the presence of complications: urethrocutaneous fistula and glanular dehiscence. Surgical (surgeon, operative time, block type, local anesthetic, meatal position) and patient (age at correction, prematurity) factors were additionally analyzed. RESULTS: For the primary aim, 983 patients underwent primary hypospadias correction with a minimum of 1 year of postoperative followup data. There were 897 patients (91.3%) in which no complications were identified and 86 (8.7%) with either urethrocutaneous fistula (81) or glanular dehiscence (5). Of the 86 identified complications, 45/812 (5.5%) were distal, 41/171 (24%) were proximal (p <0.001) with a complication. Rate of complications was not associated with caudal block (OR 0.67, 95% CI 0.41-1.09; p=0.11). On univariable analysis, age (OR 1.12, 95% CI 1.04-1.20; p=0.04), surgical duration (OR 1.02; 95% CI 1.01-1.02; p <0.001), prematurity <32 weeks (OR 4.38, 95% CI 1.54-4.11 p <0.001) and position of meatus as proximal (OR 5.38 95% CI 3.39-8.53; p <0.001) were associated with an increased rate of complications. However, on multivariable analysis, associations of age (OR 1.13, 95% CI 1.05-1.22; p=0.001), surgery duration (OR 1.01, 95% CI 1.01-1.02; p <0.001) and meatal position (OR 3.85, 95% CI 2.32-6.39; p <0.001) were associated with increased rate of complications. CONCLUSIONS: Our data suggest that meatal location, older age, extreme prematurity and surgical duration are associated with increased incidence of complications (urethrocutaneous fistula and glanular dehiscence) following hypospadias correction. Analgesic block was not associated with increased hypospadias complication risk.

Analysis of 1478 Cases of Hypospadias Repair: The Incidence of Requiring Repeated Anesthetic Exposure as Well as Exploration of the Involvement of Trainees on Case Duration.

BACKGROUND: Recently, there has been significant focus on the effects of anesthesia on the developing brain. Concern is heightened in children <3 years of age requiring lengthy and/or multiple anesthetics. Hypospadias correction is common in otherwise healthy children and may require both lengthy and repeated anesthetics. At academic centers, many of these cases are performed with the assistance of anesthesia and surgical trainees. We sought to identify both the incidence of these children undergoing additional anesthetics before age 3 as well as to understand the effect of trainees on duration of surgery and anesthesia and thus anesthetic exposure (AE), specifically focusing on those cases >3 hours. METHODS: We analyzed all cases of hypospadias repair from December 2011 through December 2018 at Texas Children's Hospital. In all, 1326 patients undergoing isolated hypospadias repair were analyzed for anesthesia time, surgical time, provider types involved, AE, caudal block, and additional AE related/unrelated to hypospadias. RESULTS: For the primary aim, a total of 1573 anesthetics were performed in children <3 years of age, including 1241 hypospadias repairs of which 1104 (89%) were completed with <3 hours of AE. For patients with <3 hours of AE, 86.1% had a single surgical intervention for hypospadias. Of patients <3 years of age, 17.3% required additional nonrelated surgeries. There was no difference in anesthesia time in cases performed solely by anesthesia attendings versus those performed with trainees/assistance (16.8 vs 16.8 minutes; P = .98). With regard to surgery, cases performed with surgical trainees were of longer duration than those performed solely by surgical attendings (83.5 vs 98.3 minutes; P < .001). Performance of surgery solely by attending surgeon resulted in a reduced total AE in minimal alveolar concentration (MAC) hours when compared to procedures done with trainees (1.92 vs 2.18; P < .001). Finally, comparison of patients undergoing initial correction of hypospadias with subsequent revisions revealed a longer time (117.7 vs 132.2 minutes; P < .001) and AE during the primary stage. CONCLUSIONS: The majority of children with hypospadias were repaired within a single AE. In general, most children did not require repeated AE before age 3. While presence of nonattending surgeons was associated with an increase in AE, this might at least partially be due to differences in case complexity. Moreover, the increase is likely not clinically significant. While it is critical to maintain a training environment, attempts to minimize AE are crucial. This information facilitates parental consent, particularly with regard to anesthesia duration and the need for additional anesthetics in hypospadias and nonhypospadias surgeries.

Heterotopic Cardiac Transplantation: Long-term Results and Fate of the Native Heart.

BACKGROUND: The long-term results of heterotopic cardiac transplantation have not been well defined. Patient survival rates and the fate of the native heart remain unclear. METHODS: This study is a retrospective review of all 46 heterotopic cardiac transplantations performed at a single institution, the Texas Heart Institute in Houston, Texas, between 1982 and 2017. Four patients who underwent heterotopic transplantation as an emergency procedure for cardiogenic shock were excluded. Three of the procedures were repeat transplantations in patients who had previously undergone heterotopic transplantation; the 3 repeat transplantations were excluded, but the original procedures were not. Follow-up was 100% complete for mortality and 77% complete (30 of 39 patients) for assessment of preoperative indication for surgery and postoperative cardiac function. RESULTS: For the 39 patients, the 1-year, 5-year, and 10-year survival rates were 69%, 36%, and 21%, respectively. One patient remains alive 25 years after the transplantation procedure. The most frequent indication for heterotopic transplantation was pulmonary vascular resistance greater than 4 Wood units (n = 11), followed by weight greater than 112.5 kg (n = 7). In most patients, native heart left ventricular ejection fraction stabilized over time to between 10% and 30%. Sinus rhythm was preserved in 87% (26 of 30) of native hearts at long-term follow-up. CONCLUSIONS: Heterotopic cardiac transplantation is an acceptable procedure that should be considered for obese patients (especially those heavier than 112.5 kg) and patients with elevated pulmonary vascular resistance (especially those with pulmonary vascular resistance >4.0 Wood units). After heterotopic transplantation, native cardiac function appears to stabilize, and there is potential for native heart recovery.

Clinical Use of the Pictorial Baxter Retching Faces Scale for the Measurement of Postoperative Nausea in Children.

BACKGROUND: Because nausea is difficult to evaluate in children, vomiting is used as the objective clinical end point in managing pediatric postoperative nausea and vomiting and postdischarge nausea and vomiting (PDNV). The recently developed pictorial Baxter Retching Faces (BARF) scale has content, construct, and convergent validity in quantifying pediatric nausea intensity. We determined its clinical usefulness in assessing pediatric postoperative nausea and vomiting and PDNV, establishing the lowest age associated with consistently reliable use, the score at which patients identify a need for therapy, and the minimum clinically relevant change in scores, and examined its test-retest reliability. METHODS: We obtained subject ratings of the severity of their nausea using the BARF and visual analog scales in the preoperative, postanesthesia care unit and postdischarge phases. Changes in nausea were rated on a 5-point Likert scale, along with responses to queries of a need for rescue antiemetics at these time points. RESULTS: Children ≥6 years of age had a consistently reliable ability to use the BARF scale (132/132 [100%] vs 59/76 [77.6%] for children ≥6 and <6 years of age, respectively, Fisher exact test, P < .001). The BARF scale had excellent performance in predicting patient-perceived need for antiemetics, with a score of 4 having 80.0% sensitivity and 85.6% specificity. The minimum clinically relevant difference in BARF scores was 1.47 (95% confidence interval, 0.84-2.1). The intraclass correlation coefficient was 0.56 (95% confidence interval, 0.34-0.73).The BARF scale identified 60 of 192 (31.3%) children as having postoperative nausea in the postanesthesia care unit, with severe nausea (score >6) in 13 (6.7%). Emesis occurred in 8 (4.1%). Rescue antiemetics were administered to 16 (8.3%), including 2 with severe emesis (≥3 episodes) but in only 2 of 11 (18.2%) with severe nausea without vomiting. PDNV was reported in 39 of the 99 who returned diaries (39.4%), with nausea in 34 (34.3%), severe nausea in 15 (15.2 %), and emesis in 16 (16.2%). CONCLUSIONS: The pictorial BARF scale is easy to use in the clinical setting by children ≥6 years of age, has a minimum clinically relevant difference of 1.47, with scores of 4 or higher associated with a patient-identified need for rescue antiemetics. Assessment of postoperative nausea by the BARF scale has shown that clinically significant nausea occurs frequently in children but is not always treated unless accompanied by vomiting.

Vaccination as a probable cause of incontinentia pigmenti reactivation.

We report a female infant with recurrent biopsy-proven vesicobullous incontinentia pigmenti occurring after her 12-month and 18-month immunizations. To our knowledge, incontinentia pigmenti vesicobullous recurrence following immunizations has not been reported. We propose that vaccinations may serve as triggers for incontinentia pigmenti reactivation.

Spreading pigmented actinic keratosis: a review.

INTRODUCTION: Spreading pigmented actinic keratosis (SPAK) is a common, but uncommonly reported or appreciated, variant of classic actinic keratosis (AK). It can mimic different pigmented lesions, which may be benign (eg, solar lentigo) or malignant (eg, lentigo maligna). OBJECTIVE: We sought to review current data and identify areas needing further research to establish diagnostic guidelines for SPAK and to increase awareness of this common entity. METHODS: A literature search was performed in both PubMed and MEDLINE databases using the search terms "spreading pigmented actinic keratosis," "pigmented solar keratosis," "pigmented actinic," and "pigmented solar." Each article was retrieved, reviewed, and summarized. RESULTS: SPAK is a rarely reported lesion that can be difficult to distinguish from other benign and malignant pigmented lesions, including seborrheic keratosis, melanoma in situ (lentigo maligna type), and lentigo maligna melanoma. Located mainly on sun-exposed areas and with a size greater than 1.5 cm, the lesion typically spreads laterally. Pathologically, the lesion resembles classic AK with increased basal melanization. The malignancy potential has not yet been elucidated but destructive therapies such as cryotherapy are recommended. LIMITATIONS: Reports not yet published or not included in the comprehensive databases we used may exist that were not analyzed. CONCLUSIONS: SPAK can be associated with adjacent melanoma in situ; therefore, its diagnosis merits increased suspicion for coexisting melanoma.

Optimizing management of actinic keratosis and photodamaged skin: utilizing a stepwise approach.

The incidence of photodamaged skin and skin lesions of all degrees of severity, from actinic keratosis (AK) to skin cancers, has dramatically increased. Actinic keratoses are pathologic, reflecting damage of essential skin cell functions and potentially progressing to invasive squamous cell carcinoma (SCC). The rate of progression is uncertain but may be as high as 10%. Because it is impossible to predict which AKs will progress to SCC, all lesions should be treated. Options include topical therapies, cryotherapy, curettage, and photodynamic therapy. Unfortunately, many individuals do not seek treatment or avoid it because of irritation, discomfort, and concern for scarring. Combining field-directed therapy and cryotherapy has been more effective than cryotherapy alone. Incorporating patient education with treatment may optimize outcomes. We propose a comprehensive 5-step approach for managing AK lesions and photodamaged skin that includes periodic clinical skin examinations; treating AK lesions with a combination of field- and lesion-directed therapy; and patient education regarding sun-protective measures and regular skin self-examinations.

Primary 2D versus primary 3D polyp detection at screening CT colonography.

OBJECTIVE: Disparate results from the existing large CT colonography (CTC) trials suggest that 2D polyp detection is less sensitive than 3D detection, but no direct evidence exists to support this claim. Our goal was to assess the sensitivity of primary 2D polyp detection with cases from the Department of Defense CTC screening trial and compare results with the primary 3D evaluation and previous 2D CTC trials. MATERIALS AND METHODS: Ten radiologists, blinded to polyp findings, retrospectively interpreted 730 consecutive colonoscopy-proven CTC cases in asymptomatic adults using a primary 2D approach, with 3D reserved for problem solving. Primary 2D CTC performance was compared with the primary 3D CTC results from the original trial of 1,233 asymptomatic adults. The 10 2D reviewers were significantly more experienced in CTC interpretation (> 100 cases interpreted) than the six reviewers from the original 3D trial. RESULTS: Primary 2D CTC sensitivity for adenomas > or = 6 mm was 44.1% (56/127), compared with 85.7% (180/210) at 3D (p < 0.001). Sensitivity of 2D CTC for adenomas > or = 10 mm was 75.0% (27/36) compared with 92.2% (47/51) at 3D (p = 0.027). Similar sensitivity trends were seen for the by-patient analysis and for all polyps at the 6-mm and 10-mm thresholds. By-patient specificity for 2D evaluation at the 10-mm threshold was 98.1% (676/689), compared with 97.4% (1,131/1,161) at 3D evaluation (p = 0.336). CONCLUSION: Primary 2D CTC is less sensitive than primary 3D CTC for polyp detection in low-prevalence screening cohorts. The disappointing 2D sensitivity in this study was very similar to results obtained with primary 2D evaluation in previous CTC trials.

Linear polyp measurement at CT colonography: in vitro and in vivo comparison of two-dimensional and three-dimensional displays.

PURPOSE: To compare the accuracy of polyp measurement at computed tomographic (CT) colonography by using two-dimensional (2D) multiplanar reformation (MPR) and three-dimensional (3D) endoluminal displays obtained both in a colon phantom and at clinical examinations. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval, and all patients provided signed informed consent, both of which allowed for additional retrospective evaluation. Two-dimensional and 3D CT colonography displays were generated from data obtained in an in vitro colon phantom that contained 10 6-13-mm synthetic polyps and from data obtained at in vivo clinical CT colonography examinations performed in 10 patients (five men, five women; mean age, 56.3 years) with proved polyps (size range, 7-25 mm). The reference standard for in vivo polyp size was optical colonoscopic measurement with a calibrated linear probe. Polyps were measured at CT colonography with 2D MPR and 3D endoluminal displays and electronic calipers by four radiologists who were unaware of the reference size measurements. The largest of the three 2D MPR measurements was considered the "optimized" 2D projection. Statistical analysis was performed with Wilcoxon signed rank, repeated-measures analysis of variance, and paired t testing. RESULTS: For the phantom, the mean errors (differences between actual polyp size and that measured at CT colonography) for 2D transverse, 2D coronal, and 3D endoluminal displays were 1.6 mm +/- 0.8 (standard deviation), 1.4 mm +/- 0.7, and 0.8 mm +/- 0.5, respectively. For in vivo polyp measurements, the mean errors for 2D transverse, 2D coronal, 2D sagittal, and 3D displays were 4.4 mm +/- 3.5, 3.8 mm +/- 3.3, 4.6 mm +/- 3.0, and 1.9 mm +/- 1.6, respectively. The 2D measurements underestimated actual polyp sizes in all cases. The differences in mean errors between 2D MPR and 3D endoluminal measurements were significant (P < .05). When the optimized 2D view was considered for in vivo measurement, the mean error decreased to 3.0 mm +/- 2.6 (P = .2). CONCLUSION: Linear polyp measurement on 3D endoluminal views was significantly more accurate than measurement on 2D transverse, coronal, or sagittal views, both in vitro and in vivo, for the CT colonography system evaluated. Use of the optimized 2D view substantially reduced 2D measurement error and may be valuable when used in conjunction with 3D measurement.